
Class 
Book 



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CDEffilGHT DEPOSm 



MANUAL 

OF 

LABORATORY DIAGNOSIS 



Compiled and Elaborated by 
Herman John Bollinger, S. B., M. D. 

Assistant in Bacteriology 
Johns Hopkins University 



Preface by 

Sidney R. Miller, S. B., M. D. 

Associate in Clinical Medicine 
Johns Hopkins University 



BALTIMORE. MD. 
MEDICAL STANDARD BOOK CO, 



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Copyright 

1919 

Medical Standard Book Co. 

Baltimore, Md. 



mR "5 19 



Press of , > ' 

The Medical Standard Book Co. 
Baltimore 



CI.A5L2476 



This book is compiled 

irom lectures given by the 

following instructors 

at the Johns Hopkins 

Medical School. 



S. R. Miller, M. D., Lectures on Urine, and Blood. 

Marjorie D. Batchelor, M. D., Lectures on Stomach 

Analysis. 

F. A. Evans. M. D., Lectures on Sputum and Stools. 

W. A. Baetjer, M. D., and S. R. Miller, M. D., Lectures 

on Blood. 

C. G. Guthrie, M. D., Lectures on Parasites. 



PREFACE. 

Requests have come from time to time for out- 
lines of the general course in Clinical Microscopy, as 
given at the Johns Hopkins Medical School, or for 
summaries of the individual subjects covered. Such 
outlines have not any particular merit other than 
that they serve as guides for teaching, or compends, 
useful for the quick reviewing of any particular 
topic. It has always seemed a wiser policy to en- 
courage each student, carefully to take his own 
notes and prepare for himself such a working out- 
line as best suited his own needs. Condensed notes 
and compends in general are too prone to stimulate 
superficiality to warrant their unqualified recom- 
njendation. Moreover the practice here has been to 
have each instructor cover a different subject each 
year, thereby ^\idening the scope of each man's 
knowledge and interests; each improving on his 
predecessor's lectures, if possible. Consequently, no 
set plan is followed and stereotyped lectures have 
been consistently avoided. 

The present summary of the lectures given in the 
past year, is published chiefly as a result of the en- 
thusiasm and painstaking work of one of the stu- 
dents. It is not intended that these notes shall be 
comprehensive: the interpretation of tests, etc., has 
not been given much space, and, by reason of the 
universal "war-time lack of time," careful correction 
has not been possible. The notes are presented 
merely as representing the essential subject m^^tter 
covered in the lectures on urine analysis, exaniina 
tion of the gastric contents, sputum, feces, parasi- 
tology and hematology. The publication of these 
notes had the sanction of the late Dr. Theo. Janeway, 
whose interest in the application of clinical labora- 



tory methods to the diagnosis of disease was always 
keen and enthusiastic. It had been his intention to 
write this preface as evidence of his approval of the 
project. B}' reason of their absence in France, Drs. 
W. A. Baetjer, C. G. Guthrie and Frank Evans have 
been unable to review the sections previously cov- 
ered by them. Knowing full well their great interest 
in the subject, it has seemed wise for me to stand 
sponsor for them all, and to permit publication, but 
only with a clear understanding of the limits of the 
book, the constant changing of methods and inter- 
pretations, and the lack of balance unavoidable in 
a work of this kind. 

Sydney K. Miller^ M.D. 
The Clinical Laboratory, 

Johns Hopkins Medical School. 



ALBUMINURIA 

Definition: The accumulation of a coagulable 
protein in the urine. The protein has, in true cases, 
escaped through the renal parenchyma. 

Two groups : 

1. True condition in which the renal parenchyma 
is faulty. 

2. False. Condition in Avhich the protein has 
been added to the urine during its passage through 
the G. U. tract. 

Origin : 

1. Blood protein. 

2. Secretion or degeneration of renal cells. 

3. Substances added along G. U. tract. 

No chemical method has been devised to differ- 
entiate these ditlerent forms. Most of protein is of 
blood origin all agree. 

Serum albumin. Greatest in frequency and 
amount. 5 to 40 grams per day. 20 to 100 mg. oc- 
curs normally, but is not detectable. Albumin is 
only clinically present when it can be detected by 
the ordinary laboratory means. This is set as a 
standard. Serum albumin is soluble in water, co- 
agulable by heat, precipitated by alcohol and salts of 
the heavy metals, and by saturation with magnesium 
sulphate, and is Levo-rotatory 62 degrees. 

Serum globulin. This is always present with serum 
albumin. It represents from 10 to 75 per cent of total 
protein. It is insoluble in water and dilute acetic 
acid in the cold. It is precipitated by saturation with 
magnesium sulphate and half saturation with am- 
monium sulphate and partially precipitated by so- 
dium chloride saturation. 

Pseudo-glohuliUy euglo'dulin^ and fibrinogen. These 
belong to the globulin group. Fibrinogen is practi- 



8 

cally never en countered and when it is is perfectly 
obvious, for the urine undergoes spontaneous clot- 
ting. Euglobulin and pseudo-globulin are probably 
the same as nucleo-albumin. They are of no practi- 
cal importance. 

jSiucleo-histones are of no practical significance. 

Bence-Jones protein is protein sui generis. 

Alhumoscs are characterized by a tendency to be 
soluble upon heating and insoluble upon cooling. 
They are increased in acute types of nephritis and 
in the absorption of exudates. 

OCCURRENCE OF ALBUMINURIA. 

1. With renal lesion. 

2. Without renal lesion. 

Occurrence of albuminuria without definite renal 
lesion. 

1. Severe muscular exercise. 

2. Severe emotional upsets. 

3. After cold baths. 

4. Alimentary ingestion of excessive amounts of 
proteins. 

5. New-born, first 8 to 10 days of life. 

6. Pregnancy, toward the end or after parturiton. 

7. Adolescence, 12 to 16 years of age. 

8. Hypostatic, associated with large spleens, no- 
ticeable after the patient has lain down for some 
time. 

9. Cyclic, orthostatic, or lordotic. This type oc- 
curs in young adults, 12 to 20 years of age. Albu- 
min appears only after the patient has been up and 
about for some time. Early morning urine is al- 
bumin free. These patients usually have abnormal 
lordosis, and w^hen corrected the albuminuria clears 
up. According to Jehle there is a deficiency of 
renal function while the patient is standing, which 



clears up when he lies down. The condition does 
not predispose one to nephritis, bnt tends to clear 
up as the x^atient grows older. 

Salient features of functional disturbance. 

1. Albumin slight. 

2. Occurs chiefly in young people. 
8. Transient or intermittent. 

4. Occurs without other evidences of renal disease. 

5. No renal disease etiology. 

6. Patients tend to be a bit peaked and have a 
neurotic tendency, with vasomotor instability, der- 
matographia, etc. 

Alhurninuria in those with transient renal injury. 

1. Fevers (with casts). Disappears with the dis- 
appearance of the fever and patient does not suffer 
inconvenience during rest of life. 

2. Toxic. Caused by drugs and secondary to 
other states such as pj'^orrhea, genito-urinar\^ infec- 
tion, etc. Dental treatment, etc., may clear up con- 
dition. 

3. Hematogenous. Caused by altered condition 
of blood as in leukaemia, pernicious anaemia, pur- 
pura, scurvy, beriberi, and jaundice. 

4. Traumatic. Caused by injury in the vicinity 
of the kidney or in remote parts of the body. Occurs 
in epilepsy, brain tumors, and sometimes after 
bimanual palpation of the kidney as well as other 
abdominal manipulations. 

5. Intermittent, characterized b}' periodic occur- 
rence, indicative of: 

(a) Insidious development of nephritis. 

(b) Stasis. 

Summary. 

Kegard faint traces of albumin in people under 20 
years of age in good condition as functional. Ex- 



10 



amine last voiding at night and iirst in tlie morning 
to determine whether it is orthostatic, or hypostatic. 
Use care to exclude extra-renal sources of albumin, 
bladder infection, vaginal discharge, etc. Regard 
albuminuria in febrile and toxic conditions as ne- 
phritis, at that time at least. One cannot judge the 
extent or the type of nephritis by the frequency of 
albuminuria. The absence of albumin and casts does 
not exclude nephritis. 

Detection of proteins in the urine: Serum albu- 
min, serum globulin, nucleo-albumin, and albumoses. 

1)1 order to detect these substances the iirine must 
he: 

1. Absolutely clear, especially if small traces are 
to be detected. Make urine clear by filtration or by 
the us^e of kieselgMhr or animal charcoal. When the 
urine comes tiirough the filter paper turbid add 
about 1/10 volume of kieselguhr and refilter. 

2. Urine should be faintly acid. 

^. Urine should not be too concentrated or too 
dilute. In cases where it is very dilute 1005 to 1006 
specific gravity, it should be made more concen- 
trated by the addition of about 1/10 volume of so- 
dium chloride. 

4. In doubtful cases don't rely on one test alone. 

Heat and acetic acid test. 

After the urine has been made clear by the above 
methods take a test tube about 2/3 full of the clear 
urine and heat the upper third in a bunsen flame. 

If no cloud appears the urine is x)robably normal. 

If a marked cloud appears it can be : 

1. Calcium phosphate. 

2. Calcium carbonate. 

3. Albumin. 

In order to differentiate these add 5 per cent acetic 



11 

acid drop b}' drop. If cloud is due to calcium phos- 
phate it disappears ; if it is due to calcium carbonate 
it disappears with the evolution of gas ; if it is due 
to albumin it persists, Ix-comes greater or becomes 
slightly less, in accordance Avith the amount of the 
former substances present. It must be remembered 
that these protein substances are soluble in an ex- 
cess of acid or alkali. To detect very faint traces 
use a dark background. 

Sources of error: (a) Technique, (b) Other pre- 
cipitable substances. 

1. ^ucleo-albumin. This is precipitated with 5 
per cent acetic in the cold. Albumin is only pre- 
cipitated after heating. 

2. Eesinous acids such as cubebs, guiac, etc., give 
a precipitate with heat and acetic acid. These if 
shaken with alcohol or ether are dissolved. 

3. Albumoses. The precipitate of these comes 
down after cooling, and reheating gives re-solution. 

Heat and nitric acid test. 

Heat urine to boiling and add 20 per cent HNO3 
drop by drop. A cloud is fairly indicative of albu- 
min. It has the same sources of error as the heat 
and acetic acid test. 

These two tests are sensitive to .005 grams in 
100 cc. 

Heller's test. 

Urine and concentrated H]S^Oo are layered in equaJ 
parts, the urine above and the acid below. 
A cloud at the line exactly can be : 

1. If white, albumin. Its breadth depends upon 
the quantity of albumin present. xA^fter a time it 
tends to diffuse upwards. 

2. Thymol. This has a grayish or brownish color. 
There is also a zone of oreenish color below and a 



12 

reddish one abo\e llic^ line of contnct. ronfirm b}' 
t^haking with petroleum ether. 

3. Albumoses. Tlie cloud given by these is ideii- 
lical with that of albumin. J>y heating this cioud 
disappears. 

4. Urea nitrate. This cloud is yollowisli brown 
and is made up of crystals which give a shimnier. 

A cloud above the line of contact may be: 

i. A broad, yellowish band about II/2 cm. above 
line of contact due to urates in concentrated urines. 
They are dissolved by heating. 

2. Xucleo-albumin gives a cloud ^4 to % cm. above 
the line of contact. It tends to disappear by dilu- 
tion. By diluting the urine to 1005 to 1008 nucleo- 
albumin and albumoses can be eliminated. 

This test is sensitive from .002 to .007 grams per 
100 cc. 

Potassium ferrocyanide and acetic acid test. 

From 5 to 10 cc. of urine in a test tube to which 
is added acetic acid. Do not heat. Filter and to 
the nitrate add 10 per cent potassium ferrocyanide, 
drop by dro]). Albumin gives a whitish precipitate. 

Sources of error: 

1 . Iron present in large amounts. Color different. 

2. Boiling urine in a glass container. 

3. Reagent itself. 

4. Albumoses which upon heating disappear, 

5. ^ucleo-albumin same as albumoses. 

QUANTITATIVE TESTS FOR ALBUMIN. 

The most common and easily performed is the em- 
ployment of the Esbach tube. It differs in accuracy 
from the Kjeldahl metliod by .3 gm. Urine is added 
to the mark U and reagent to the mark E. The 
tube is inverted ten or twelve times to insure thor- 
ough mixins,- of the contents and is then allowed to 



13 

stand for about 24 hours and read. The reading 
below gives the number of grains per liter. 
Reagents useds 

1. Picric acid. This is merely mentioned to be 
condemned. It not only precipitates albumin but 
also albumoses, uric acid, creatinin, resinous acids, 
etc. 

2. Tsucliiya'S reagent. 

Phosphotungstic acid 1.5 grams 

Concentrated HCl 5.0 cc. 

95 per cent alcohol g. s. ad. . . .100.0 cc. 
The advantage of this reagent is that it eliminates 
the above error. 

The disadvantages of the test are that it is inac- 
curate in urines containing over 4 per cent albumin ; 
and in some cases the precipitate sticks to the sides, 
may float or may settle unevenly. 

OLOBTTLINS: 

Purdy's test. 

Globulins are soluble in salt solution, but insolu- 
ble in distilled water. Dilute the urine and get a 
cloud, or, better still, drop the urine in a test tube 
half full of distilled water and watch for a cloud 
against a black background. 

Ammomum suliyliata method. 

Make the urine alkaline with amrnroniura hyd^65^ 
ide and filter. Layer equal amounts of the filtrate 
and saturated ammonium sulphate. A cloud at the 
line of contact is fairty indicative of globulin. For 
more accurate determination do following test : Urine 
plus equal volume of saturated ammonium sulphate 
solution. Let stand an hour and filter. Wash pre- 
cipitate with half saturated amonium sulj^hate until 
filtrate is albumin free. To further differentiate it 
dissolve precipitate in water and heat on Avater 



14 



bath to coagulate the proteins. Filter and wash 
the precipitate with water. To the precipitate add 
1 per cent solution of sodium carbonate and heat 
on the water bath. Filter and neutralize with 
acetic acid. A precipitate signifies globulin (Web- 
ster). ' - 

BENCE-JONES PROTEIN. 

(S. K. Miller and Walter A. Baetjer, J. A. M. A., 
1-19-18, vol. 70, pg. 137-139.) 

Tliis is the most infrequent type of protein found 
in the urine. In 1816 Bence-Jones described the 
characteristics of the protein, which were tlie forma- 
tion of a gelatinous precipitate at a low temperature 
wliich disappeared upon boiling and reappeared 
uj)on cooling. In 1876 Rustizky described multiple 
myeloma. In 1889 Kahler described a case of mul- 
tiple myeloma with Bence-Jones protein in the 
urine. The association of multiple myeloma with 
Bence-Jones protein is almost constant but not spe- 
cific, for it does occur in other conditions. In no 
case, however, where Bence-Jones protein has been 
found has the bone-marrow been found to be normal. 
Multiple myeloma are bone tumors similar to sar- 
coma, occurring usually in people beyond forty 
years of age, and in men more than in women. The 
condition is one of a deep-seated bone lesion asso- 
ciated with pain, emaciation, cachexia, etc. ; it is con- 
fined to the marrow and lives at the expense of the 
cancellous, tissue; it is limited to the long bones, the 
sternum and* ribs, rarely invoMng the skull. 

Bence-Jones protein has /been demonstrated in five 
types of cases : '"■■■■'■ 

1. Multiple myeloma composed of (a) myeloblasts, 
(b) myelocytes, (c) erythroblasts. . 



15 



2. Chronic leukaemias (a) lympliatic. (bi niTelo- 
cytic. 

3. Metastasis to bone from cancer elsewhere. 

4. Other bone diseases present. 

5. Cases without any lesions present. 

Usually not over two years elapse from the dis- 
covery of Bence-Jones protein to the death of the 
individual. In tAvo cases there was reported a high 
blood pressure. 

Xature of Bcncc-Joncs protein. 

It gives rise to amino acid partition and is there- 
fore a real protein, but it differs from any other 
known protein and is never found to be a part of the 
metabolism of the individual. It contains a car- 
bohydrate radicle, but no phosphorous, and is there- 
fore not a nucleo-protein. It also contains from 1 
to 2 per cent of sulphur. It has been injected subcu- 
taneously, intravenously and intrarectally, but is al- 
ways excreted as such. 

Theories regarding Bence-Jones protein. 

1. A substance derived from the secretory activity 
or degeneration of tumor masses themselves. 

2. The tumor itself secretes an enzyme which can 
influence protein metabolism in such a manner that 
this protein is formed. 

3. Individuals with Bejice-Jones protein have 
anomalies in urine excretion and metabolism similar 
to those excreting alkapton and cystin substances. 
It is probable that these individuals on account of 
their perverted metabolism are more prone to 
tumors. 

Character of the urine. 

The amount varies from 1200 to 2000 cc. per day 
with a normal specific gravity. It has a pale smoky 
color but is clear; it is acid in reaction, rarelv neu- 



16 



tral or alkaline ; it has a tendency to foam on shak- 
ing, which foam is more abundant and more per- 
sistent than normal. There may be as mncb as 70 
grams of the protein present in the 24 honi speci- 
men, and there is no other type of protein nor any 
casts present unless there is some nephritic condi- 
tion superimposed. 

ClwracteriMics of the urine in this disease. 

1. Continuous excretion regardless of everything. 

2. Intermittent type, in which days or months 
may elapse without its excretion. 

3. The appearance of the Bence-Jones protein 
sometimes antedates any demonstrable lesion. 

4. The largest amounts are excreted in multiple 
myeloma which may run as high as 50 to 75 gm. per 
day. In other cases, such as metastatic cancer or 
sarcoma, from 20 to 35 gm. are excreted. 

5. There is also a decreased chloride content. 

6. A spontaneous precipitate may occur in the 
urine after standing for some time or it may occur 
in the bladder and give rise to a urine resembling 
chyle. 

Tests. 

1. Heat and acetic acid. The urine clouds at 
about 55 degrees. It is coagulated and precipitafed 
from 10 to 20 degrees lower than any blood protein 
(40 to 60 deg.) It dissolves upon boiling and re- 
appears upon cooling. Coagulation depends upon 
the acid and salt concentration of the urine. 

2. Urine treated with 25 per cent HXOg in the 
cold gives a cloud which redissolves at first until 
excessive acid is added. This precipitate is soluble 
at 100 deg. and insoluble at 60 deg. Any dilute 
mineral acid will do the same. 

3. Urine plus 2 volumes of saturated ammonium 



17 

sulphate gives a complete precipitation at room tem- 
perature. This precipitate is readily soluble in 
water and does not pass through a dialysing mem- 
brane, differing from albumoses and pentoses. 

4. Urine plus 2 volumes of a saturated solution of 
sodium chloride gives no precipitate unless the 
urine is previously acidified with acetic acid. The 
precipitate is not soluble in water. 

5. Urine j)lus 2 volumes of 95 per cent alcohol 
gives complete precipitation. Immediately after 
precipitation, the precipitate is soluble in water, but 
if kept in contact with the alcohol for some time, it 
becomes insoluble in water, but is soluble in a dilute 
solution of ammonia. 

6. It gives a positi\'e biuret reaction. 

SEDIMENTS OF THE CRINE. 

Inorganic. 

1. Acid urine 
a Uric acid. 

6 Amorphous urates. 

c Calcium oxalate and sulphate. 

d Xanthine. 

e Cystiu. 

/ Leucin. 

g Tyrosin. 

h Hippuric acid. 

i Bilirubin. 

/ Cholesterin. 

2. Alkaline urine. 

a Amorphous phosphates and carbonates. 
h Magnesium phosphate, 
c Triple phosphates. 
d CaCOg. 

e Ammonium biurate. 
One mav find anv kind of acid crvstals in an 



18 

alkaline urine i'or they may persist after the urine 
has become alkaline. 

Uric acid crystals. 




There are three conditions necessary for their for- 
mation : 

1. Concentrated urine; 2. High acidity; 3. Cold. 

They form crystals brick red in color and have 
a tendenc}' to clins to the sides of the container. 
They mean nothing concerning purine metabolism. 
They take a variety of shapes, rhomboid, prisms, etc. 
When made arti-licially they are colorless. They 
are soluble in HCl and insoluble in acetic acid. 

Urate sediments. 

These also occur when the urine is : 1. highly acid ; 
2. concentrated, and 3. cold. They take the urinary 
pigments with them, urochrome and uroerythrin. 
Their shape is amphorous, sometimes resembling 
needles. They are soluble by heating to 50 to 60 
degrees, and with acetic and mineral acids. 
Calcium oxalate crystals. 



These are formed mostly from vegetables such as,.. 
rhubarb, celery, spinach, peas and beans, and also, 
from green fruits. A small portion is formed from: 
the body (nucleins — uric acid — oxalic acid). In ox- 
aluria as much as 20 to 30 grams may be excreted 
in a day on a mixed diet. Neurasthenia is often as- 
sociated with its excretion but not the cause. Its 
excretion is sometimes increased in jaundice, and 
hepatic disease, and definitely increased in gout 



19 

when it is most likely formed from uric acid. In 
this condition determine whether it is excreted fre- 
quently and whether it is associated with uric acid 
])erversion and calculi formation. They occur as 
four-sided prisms with a square base and also in 
dumbbell crystals. 

They are perfectly white in color, are insoluble 
in acetic acid, but soluble in HCl. 
Calcium sulphate. 




These are perfectly white in color and rare in 
occurrence. Their shape is long and oblong. 
XantMn, white and somewhat egg shaped. 




(After Hawk) 
Tyrosin, colorless and in needles arranged in 
sheathes and rosettes. 




Leucin, never a spontaneous sediment. 



Cystin, colorless, four-sided or prism shaped 
crystal?. Insoluble in acetic acid and soluble in HCl. 



o^ 



20 



Hippuric acid. Occur rarely. They are irregu- 
lar, six-sided crystals. 



C^ 



Bilirubin crystals, yellow or reddish browu in 
color, occur rarely in hemorrhagic nephritis, after 
transfusion, jaundice, and acute yellow atroph}^ Oc- 
cur in needles and rhomboid shaped crystals. 

Cholesterin crystals, white, and, in the form of 
steps, one upon the other. Soluble in chloroform. 




AmorpTioiis pTiospliates and carbonates. 

These constitute the chief sediment of alkaline 
urine. Both are soluble in acetic acid, the car- 
bonates in addition give off gas. 
Magnesiutn pliosphate. 

These are generally amorphous but occasionally 
resemble triple phosphates. 
Triple phosphates. (MgNH^PO^) 



^^ 



These are one of the commonest forms of xls found 
in standing urine, and are characteristic of am- 
moniacal urine. These are coffin-lid, or when 
eroded, fern-leaf in appearance. They are colorless 
and soluble in acetic acid. 



21 

Calcium carhonate crystals. 



These may be amorpiious or crystalline and are 
generally found with amorphous phosphates. In 
shape they are either dumb-bell or spheroidal with 
concentric radiations. They are colorless and solu- 
ble in acetic acid with evolution of gas. 
Ammonium blur ate crystals. 



/ 



These occur in the shape of thorn-apples and are 
dark brown in color. They dissolve in acetic acid 
and give uric acid. They are of no significance. 

bCHEME FOR RUNNING DOWN INORGANIC SEDIMENTS. 

1. Warm sediment. 

a Urates readily soluble. 

6 Calcium sulphate soluble with difficulty. 

2. If not soluble by (1) add 3 to 5 drops of glacial 
acetic acid. 

Solution indicates : 

a Amorphous phosphates and carbonates. 

h Triple phosphates. 

c Calcium carbonate. 
Non-solution indicates : 

a Uric acid. 

h Calcium oxalate. 

c Calcium sulphate. 

d Organized sediments. 

e Tyrosin. 

/ Cystin. 

g Leucin. 

3. Add from 3 to 5 drops of concentrated HCl to 
insoluble sediment. 

Solution indicates: 



22 

(/ Calcium sulphate. 
h Cystin. \ 

c Tyrocin. ( These are also soluble in 
d Leucin. ( IS^H^OH. 
e Xanthin. ) 

4. Uric acid is insoluble in acids and ammonia; 
but is soluble in KOH. 

5. Cliolesterin is soluble in chloroform. 

6. Hippuric acid is soluble in alcohol. 

ORGANIZED SEDIMENTS. 

Mucus threads. 

Poorly refractile, interlacing, fibres found nor- 
mally and of no significance. Kesponsible for the 
nubecula formation. 
Epithelial cells. 

These may arise from any part of the genito- 
urinary tract, viz. : pelvis of kidney, bladder, ure- 
thra, prostate. Irregular cells occur in the bladder 
and vaginal tract. Sheets of cells are more fre- 
quent from the vagina. Kenal cells tend to be romid 
or cuboidal, a little larger than a pus cell, and i.a\e 
a large vesicular nucleus. They may occur in av) 
type of nephritis, but are more apt to occur in larger 
nimibers in acute nephritis. Similar cells arise 
from the ureter and prostate, those from the latter 
being about twice as large. One cannot tell the 
type, location or extent of the lesion by the type of 
cell found, although renal epithelium does nr t oc- 
cur normally. Tailed cells were formerly thoiiglit 
to arise from the pelvis of the kidney, but they are 
also found in the deeper layers of the bladder and 
vagina. 
Pus cells. 

A few may be encountered in normal sj)ecimGn,-^., 
especially in women. Large numbers indicate patho- 



23 

logical conditions either of tlie G. U. tract or outside. 
The number of pus cells occurring in diseases of tlie 
cortex of the kidney is few ; the number occurring in 
pyelitis, pyelonephritis, and kidney abscess is many. 
Cystitis is the most frequent cause of pus in the 
urine. They are better identified in acid urine, so 
accordingly, if the urine be alkaline as it usually is 
in cystitis, it will aid in identification by adding a 
lew drops of acetic acid under the cover slip, which 
will bring out the nuclei. 
Tripperfadcn. 

Are shreadlike bits which float about. Micro- 
scopically they are masses of pus cells in the meshes 
of mucus. They occur in chronic urethritis. 
Red Wood cells. 

These never occur normally except in women dur- 
ing menstruation. They disintegrate very rapidly, 
tend to be slirunken and crenated in concentrated 
urine, laked in urine of low specific gravity, and are 
often difficult to recognize. When they arise from 
the kidney they tend to be mixed with the urine, 
when from the bladder they tend to occur in clumps. 
In alkaline urine they tend to go to pieces very 
quickly. 
Spermatozoa. 

Disintegrate very rapidly. Found occasionally in 
adult males. 
Tissue jragments. 

Kenal or bladder new^ growths. 
Casts. ( Cylindruria ) . 

Descending tubular elements from the kidney. 

Theories of origin: 

1. Casts represent visible coagulated albumins 
which have escaped from the kidney. 

2. Irritated kidney cells excrete a colloidal sub- 
stance which is coagulated in the tubes and may en- 



24 

gulf any cellular substance present there at the 
time. 

They indicate a condition of renal irritation and 
are more indicati\ e of it than albumin. 
TA'pes of casts. 

1. Cellular. 

2. Granular. 

3. Amorphous. 
Cellular casts. 

a Epithelial. 

& Pus or W B C. 

c Eed blood cell. 
Granular casts. 

a Fine and coarsely granular. 

& Fatty. 

G Urate. 

d Bacterial. 
Amorphous casts. 

a Hyaline. 

1) Waxy. 
Theory. 

Hyaline casts are the fore-runners of all the 
others, and are the matrix upon which the others 
are built. They have straight sides, rounded ends, 
are uniform caliber throughout, narrow, may be 
short or long, and are poorly refractile. One can 
build all the other forms around them. Any cast 
containing even but one cell is called a cellular cast 
and designated b}^ the type of cell it contains. They 
are encountered in a number of conditions, acute 
and chronic nephritis, etc. Cellular casts change 
into granular casts, going through a stage of fatty 
degeneration. Coarsely granular casts are yello^^- 
ish in color and finely granular casts are colorless. 
Granular casts can finally revert to the hyaline form. 
Waxy casts differ from hyaline casts in being 



25 

highly refractile. They seem brittle, have irregiilai' 
ends, aud may be wavy in outline. They tend to be 
broader and have transverse lines of fission. They 
stain with Lugal's solution but are not necessarily 
limited to amyloid disease. They are a fairly good 
indication of tubular stasis and probably represent 
metamorphosed hyaline casts. 
Occurrence of casts. 

Casts are occasionally encountered in normal in- 
dividuals, but whenever they are found they should 
be regarded as evidence of renal irritation, whether 
slight, transitory, and of no importance or persist- 
ent and of serious import. They occur after strenu- 
ous exercise and in febrile states. Neither the type 
nor the number allows one to judge the extent of 
the renal injury, for the more normal the kidney 
the greater is the response to irritation. Casts tend 
to appear and run parallel with albuminuria but are 
more sensitive. The occurrence of albuminuria 
without casts usually indicates that one has not 
looked long enough or that the urine has become 
alkaline and they have disintegrated. 

Albumin without casts does not predispose to the 
development of nephritis. It gives some evidence 
of tuberculosis and other diseases higher up. 

Albumin with few casts represents in general the 
same thing as above. There is, however, a higher 
mortality incidence. 

Albumin with granular casts indicating cardio- 
renal disease, has in ten years a much higher mor- 
tality incidence than the two previous. 

Casts tend to be more cellular the more acute the 
condition. Waxy casts are indicative of tubal 
stasis. It is not so much the type nor the number of 
casts, but it is their relation to other clinical evi- 
dence that is of importance. (Read in Osier's book 



26 

of rcprLiits "On Ike Advantage of a Trace of Albuiuin 
and a Few Tnbe Casts in the Urine of Certain Men 
Above Fifty Years of Age.") 
Cylindroids. 

These may possess any and all the characteristics 
of casts. They are usnally straight and hyaline and 
larely Avaxy. 
References. 

Atlas der Clin. Mic. des Harnes, Rieder. Micro- 
scope der Harnes Sediment, A. Daiber, 

BACTERIOLOGY OF THE URINE. 

BaciUuria. 

Indicates bacilli in the urine irrespective of their 
sonrce. 
Types found : 

1 . Tubercle bacilli. They may be excreted through 
the kidney and not represent a lesion of the G. U. 
tract. When associated Avitli r. b. c. and w. b. c, 
their local source is more likely. Don't confuse with 
Smegma bacilli. To obtain a more certain dagnosis 
inoculate a guinea pig intraperitoneally, keep 3 or 
4 weeks, kill, and look for typical findings in the 
retro-peritoneal lymph glands, spleen or liver. Blad- 
der tbc. is often associated with an acid urine and 
sterile pus. 

2. Gonococci. Gram negative and intracellular. 
Difftcult to find them in ^eisser cystitis. 

3. Typhoid bacilli. Found during the disease 
and often for weeks or months after recoverj^ May 
be due to a bacillaemia or due to local lesion. 

4. Colon bacillus. Common invader and cause of 
pyelitis and cystitis. 

5. Paratyphoid. Infrequent cause of pyelitis. 
C). Cocci often found with Neisser infection. 

7. Streptococci often occur from systemic infec- 
tion, nephritis, etc. 



o 

H 

Q 

O 



a. 



B 


Improves as 
Heart May 

Get 
Infarction 


B. P. Nor- 
mal Oedema 
(Face 1st) 
Uraemia 


Cure Rare 

Oedema 

Anasarca 

Uraemia 

Cardiac Fail 


B. P. Incr. 

Dropsy 
Rare. Car. 
Hyper Apo- 
plexy 


B. p. Norm or 
Below Oe- 
dema Com. 
Ureamia 
Rare 


Associated Willi Fever 
& Cachexia May Lead 
Amyloidosis, Septic- 
aemia or feritoiiltis 
From Perforation 


o 


03 
< 


CO C 
V 

^ 2 


en 

rs] C 


en 

a; 




en en 

l2 


> 

o 


^^1 

c(5 <U C 


5 = g 1.o|„ 

III ir 'r^ 


c: S h h" o-ti 


2 

J_ O CiO 

o 


H 

'a? 

5 


'" O ^ V} 




03 en =: 55 

II 5 s 

a> +j _ Xi 
O w ^ 03 

Q < Ph 


o s ^ 

S^ ^ IS «J 

^ a; ^ v-i 


? V = 


en 

■T. 


2; 

< 


5 


^ en en 


en 

(U -^ 

< 


03 « 


en 

rt 2 


5 


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Ah" 

;/5 


"to 


a 

o 

2; 


'So 


o 


o 

03 O 

5 ii 


c 
o 


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t-r 

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in 03 

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s 





27 

8. Any organism in the blood may be swept 
through the kidney. This may be the cause of much 
nephritis due to kidney injury. The general methy- 
lene blue stain detects all the bacteria except two : 

1. Acid fast bacilli. Use carbo-fuchsin. 

2. Gonococci. Use gram stain. 
Animal jjarasifes in the urine. 

1. Amoeba. 

2. Echinococcus (look for hooks and laminated 
membranes ) . 

3. Filarial larvae. 

4. Eggs of Schistosoma hematobium (human blood 
fluke) or Bilharziasis (Egyptian hematuria). 

5. Oxyuris (pin worms, occasionally found in 
young girls. Wanders through urethra into bladder), 

G.. Trichomonas vaginalis (of no importance). 

GENERAL CONSIDERATIONS. 
Urine examined for the folloicing considerations : 

1. Renal and G. U. conditions. 

2. General metabolism of the body. 

3. Food metabolism. 
Urine examination criteria. 

1. Single voidings are of no practical importance. 

2. Should be carried out on 24-hour specimens and 
in some instances the day and night specimens 
should be kept separate. 

3. Fluid intake and general diet should be taken 
into consideration. 

4. Correlate urinary and clinical findings. 

5. Abnormalities should be confirmed at subse- 
quent examinations. 

Single voidings examined for: 

1. Albumin. If but a faint trace is present, ex- 
amine two specimens, one at night and one in tlie 
morning, to see whether it is orthostatic. 



28 

"2. Gross abnormalities, blood, pus, etc. 
3. Microscopical elements, such as blood, casts, 
and various forms of cr3^stals, pathological cells, and 
parasites. 

-*. Constituents requiring chemical analysis, such 
as bile, urobilin, blood, indican, acetone, diacetic 
acid, sugar, etc. 

c. Specific gravit}' determination. 
(). Keaction, acid, alkaline, or amphoteric. 
Collections of 24:-hour specimens : 
1. Establish hours between which the specimen 
is to run. If the hours determined are between 7 
A. M. and 7 P. M., have the patient void at 7 A. M. 
and throw the specimen aAvay. Collect all voidings, 
including the one at 7 A. M., the following morning. 
1*. Containing vessel should be clean at the start, 
cool, corked and clearly labeled with: 
Xame of patient. 
Date, 

Hours of collection. 
Total intake, 
Preservative used. 
3. Day and night specimens should be kept sepa- 
rate in some cases. 



29 



Preservatives used for urine : 

Tj^ie. Amount. Advaiitasro. Disadvantage. 

Chloroform 2 to 3 drams No Inilk. easily Not good for casts, 

perlirer. removed, crys- Reducing agent, 
tals preserved. 



Formalin. 


1/. to 27c by 


Preserves 


Adds bulk.reducin-.- 




volume or 5 


casts. 


agent, error in sugar 




to S drops 




test, form^^. crystals 




per L. 




with urea, inter- 
feres with urobilin 
and indican tests. 


Thymol. 


A few crys- 


Preserves 


False tests for hile 




tals. 


sediments 


and Heller's albu- 
min. 



Toluol A thin layer. No volume. Expensive and in- 

urinecnnbe flammatory. 
secured below. 

Common preservatives in nse are chloroform and 
tolnol. 
Physical properties of urine, normal and abnormal. 

1. Normally it is a cleav, tranparent shade of 
yellow. After standing 15 to 45 minutes a "nubec- 
ula;" or fog, settles to the bottom, Avhich is com- 
posed of mucus and epithelial cells. 

2. Urine cloudy when voided. 

(a) Frequently voided after heavy meals of 

vegetable*^. Due to excess of phosphates. 
Not abnormal. 

(b) Px'esehce of some kind of organized sedi- 

ment,' blood," desquamated epithelial cells, 
pus, bacteria. 

(c) Cloudy, with the smell of ammonia, indi- 

cates cystitis. 

3. Urine becomes cloudy on standing. 

(a) Development of bacteria. 

(b) Precipitates of calcium, phosphorus, and 

carbonates. Formation of ammonium 
carbonate bv bacteria. 



30 

(c) Concentrated nrine, becoming quickly 
cooled, deposits amorphous urates. 

Odor of urine. 

The normal urinary odor is due to aromatic sub- 
stances. The urinous odor is due to the action of 
bacteria. A fruity odor occurs in diabetes, due to 
the excretion of acetone. A foul odor occurs in 
urines containing large amounts of albumin, as in 
cancerous and inflammatory conditions in the lower 
G. U. tract. The ingestion of asparagus giyes a 
peculiar odor, due to methyl mercapton. Drugs, 
such as asafedita and yalerian, giye their charac- 
teristic odor. Turpentine giyes the odor of yiolets; 
menthol that of pepperment; cubebs, copaiba, tolu 
and saffran that of spices. 

Amount of urine excreted depends upon : 

1. Indiyidual himself. 

(a) Sex, males more than females. 

(b) Children yoid proportionately more, yiz: 

adults 1 cc per kilo body wt., children 
4 cc per kilo. 

(c) Weight of indiyidual. 

2. Fluid intake. 

3. Pressure and yelocity of blood current. 

4. Condition of renal parenchyma. 

5. Loss of fluid by other means: perspiration, res- 
piration, intestines, formation of transudates and 
exudates. _ 

6. Vasomotor phenomena. 

The normal excretion yaries bet^yeen 900 and 1200 
cc per day. • - Functional capacity is. from 20 -tjo- Bo- 
liters. Often on forced T^~ater 9 to 10 lifers are ex- 
creted in typhoid without damage to the kidney. 
Normally at night less is excreted than during the 
day, the ratio being 100 parts by day to 60 — 80 
parts by night. In some forms of nephritis, hepatic 



31 

insufficiencT aud cardiac disease, this ratio is re- 
versed. 

Nycturia signifies tlie excretion of more urine at 
night than during the day. It occurs character- 
istically in chronic diffuse nephritis. 

Polyuria signifies the excretion of 3000 cc or more 
urine per day. 

Causes : 

1. Increased fluid intake. 

2. Diuretics. 

3. Nervous disorders. (a) organic; (b) func 
tional. 

4. Diabetes mellitus and insipidus. 

5. Chronic nephritis. 

6. Absorption of exudates. 

7. Epicritical (end states of acute febrile dis- 
orders ) . 

S. Sometimes in ureteral stricture. 
Oliguria signifies the excretion of 800 cc or less 
in 24 hours. 
Causes : 

1. Decreased fluid intake. 

2. Loss by other means. 

(a) phj^siological 

(b) pathological 

1. Formation of exudates aiid transu^ 

dates. 

2. Acute febrile states. 

•3.- Acute nephritis. ^ ..'...' 

i. End state of chronic nephritis. 

5. Chronic diarrhoea. 

6. Vomiting. 
Anuria signifies no urine. 

Causes : 

1. Obstruction to urinary passages. 

2. Reflex (functional neuroses^ Dietl's crisis). 



32 

3. Renal, acute nephritis, or end stage of chronic 
nephritis. 

4. Prerenal conditions. Poisons : bichloride, 
arsenic, anaesthetics. Occasionally after veronal 
medication (S. R. Miller). 

Pollakiuria signifies nnduly frequent passage of 
urine. 

Occurrence : 

1. Polyuria of nephritis. 

2. Prostratic disease. 

3. Bladder disease. 

4. Ureteral stricture. 
Specific gravity. 
Methods of determination: 

1. Balance picnometer. 

2. Urinometer which is calibrated at 15 deg. C. 
The reading should be taken at the junction of the 
lower meniscus and flu^.d. The Sj). gr. depends upon 
the amount of urine excreted and the amount of 
solids therein. Sodium chloride and urea are the 
chief sources of high Sp. gr. in normal urine. Nor- 
mal urine has a Sp. gr. between 1015 and 1020 for 
1200 to 1500 cc per day. 

Clinical value of specific gravity: 

1. Estimation of total solids of urine. Haeser's 
coefficient equals 2.33 times the last two figures of 
the reading and gives the weight of solids per 1000 
cc. Normally the total solids average from 60 to 70 
grams per day on the basis of 1500 cc output. 

2. Estimation of urea (Webster). 

3. In polyurias, with low specific gravity, it points 
to chronic diffuse nephritis, and with high specific 
gravity to diabetes mellitus. 

4. Oliguria, with low specific gravity, gives bad 
prognosis in nephritis. 



33 



5. Extensive oedema, with low Sp. gr., points to 
renal trouble. 

6. Normally urines collected at intervals during 
the day show a variation in the Sp. gr. of 10 points. 
In chronic nephritis there is a tendency to the fixa- 
tion of the reading at about 1010 (Hyposthenuria). 

Reaction of the urine. 

Normal urine is faintly acid, partly from the acid 
sodium phosphate and partly from free acids, such 
as sulphuric, oxalic and hippuric, which occur when 
more animal than vegetable diet is taken. More 
acid occurs in the morning, and less after heavy 
meals. 

Variations in the total acids: 

1. Use of drugs, sodium bicarbonate and acid 
sodium phosphate. 

2. Hyperacidity increases; hypoacidity decreases 
acid. 

8. Less after intestinal hemorrhage and after 
oedema due to nephritis. 
Classification of reactions : 

1. Acid. 

2. Neutral. 

3. Amphoteric, effecting both red and blue litmus. 

4. Alkaline. 
Alkalinity : 

1. Fixed. 

2. Volatile. Hold wet litmus in the fumes of the 
urine and the ammonia tliere present turns litmus 
blue. This condition leads one to suspect inflam- 
mation of the bladder. 

Acidity of urine is due to acid sodium phosphate 
(NaHoPO,^)* and free organic acids. 



34 



Quantitative determination of acids : 
Folin's method : 

Urine 25 cc. 

Powdered Potassium oxalate 5 to 20 grams 
(Prevents dissolution of 
salts of calcium.) 
1% solution plienolphthalein 2 drops 
Titrate to the end point (a faint pink) with 
N/10 NaOH. 

The acidity is expressed in terms of : 

1. Total no. of cc. necessary to neutralize total 
24-hour output, 617 is about normal. 

2. Percentage, number of cc. necessary to neutral 
ize 100 cc. of urine, 35 to -10 per cent normal. 



COLORING MATTER OF URINE 



The normal color of urine is a shade of yellow or 
amber. Ordinarily the color varies directly with 
the specific gravity, but here are tAvo exceptions : 
(1) Diabetes, which is associated with a faint yel- 
lowish green color and may have a Sp. gr. of 1040 
or over. (2) Chlorosis, which may also be asso- 
ciated with a pale urine and high Sp. gr. 

Normal pigments of urine. 

I. Urochrome, which is responsible for most 
of the yellow color and Avhich is of little importance 
clinically. Also urocliromogen, precurser of uro- 
chrome. 

II. Uroerythrin, which is responsible for the sal- 
mon-red color. It is a pigment increased on exces- 
sive meat diet and in fevers. When extracted witji 



35 

amyl alcohol it gives characteristic spectroscopic 
bands. 

III. Urobilin, which is a complicated group of 
pigments, possessing a pyrrol nucleus. Xormal urine 
contains 30 to 100 mg. per 24 hours. 

IV. Urobilinogen, which is unstable and by sun- 
light is changed into urobilin. 

Origin of uroljilin : 

1. Hematogenous theory, that urobilin may be 
formed directh' from the blood without the inter- 
vention of the liver. 

2. Hepatic origin. Liver entirely responsible. 

3. Nephrogenous theory, that under certain con- 
ditions the epithelium of the kidney changes bili- 
rubin into urobilin. 

4. Enterogeneous theory, indicated by the dia- 
gram. 

Hcmogloltin 

I 
Biliruhin (action of the liver) 

I 
LrohiIi)i and uroljiUnogeii (action of intestines and bacteria) 

I I 

Portal system Part excreted in the feces 

I 
Liver 

I I 

'Normal Abnormal 

I I 

Bilirubin (Failure to convert) 

Hemoglobin Urobilin absorbed and excreted by the kidneys. 

Significance of uro'biVmuria : 

1. Bile is entering the intestines. 

2. Extensive blood destruction. 

3. Hepatic insufficiency. 

(a) Physiological. 

(b) Actual hepatic disease. 

4. A certain amount of renal efficiency. 

5. Absence of urobilin means total obstruction of 
the bile duct. 



36 

Occurrence of urobilinuria : 

1. Common in hepatic cirrhosis. 

2. Chronic passive congestion (prognostic evi- 
dence). 

3. Hemolytic anaemia. 

4. Malaria. 

5. Pneumonia. Appearing at the time of the 
crisis is a favorable sign, especiall}^ if the patient 
is jaundiced before. If in the serum of such a 
patient the prognosis is usually hopeless. 

G. Measles and, scarlet fever and all affections 
which lead to liver damage. Appearance of tlie 
urine in uroNlinuria. The urine takes on a dark 
3^ellowish color. Output is irregular and single void- 
ings sliOAV great variations in the amount excreted. 
Tests for urobilin: 

Schlesslnger's. 

To about 5 cc. of urine add a few drops of Lugal's 
solution, 1 to 2 cc. of NH^OH, and an equal volume 
of 10% alcoholic solution of zinc acetate. Filter 
and examine filtrate for greenish fluorescence. 

Spectroscopic examination : 
Extract with amyl alcohol. 

Alkaline solution gives broad band between E 
and F. 

Acid solution gives intensified bands in same place 
and the E — b space is filled. 

Ehrlich's 'benzaldekyde test. 

Use a 2% solution in concentrated HCl. Use 3 
drops of this reagent to 3 to 5 cc. of urine. The pres- 
ence of a pyrrol derivative gives a cherry-red color. 
Heating before adding reagent gives intensification 
of same. 



37 



V. Iiulican (Iiidoxyl sulphate) 5 to 45 mg. per da 3^ 
Animal proteins alone give it. 

_, , ] indol ^ indoxyl 

Tryptophane= | ^^^^^^ absorbed= j ^^atoxyl 

These are conjugated with sulphuric acid and ex- 
creted as sodium or potassium salts. Indicanuria 
is increased upon a meat diet and is not excreted 
on a non-protein diet. Urine is generally normal 
color when voided, but on standing becomes dark. 
Formation : 

1. Extra-intestinal, due to xDrotein decomposition 
in the body (bronchitis, abscesses and empyemias), 

2. People with inborn errors of metabolism. 

3. Gastro-intestinal tract diseases or disorders : 
(a) Transient phenomena, (b) Constant oc- 
currence, (c) Recurrent type due: 1, 
to pathological conditions of intestinal 
tract. 2. Perversion of intestinal tract 
secretion. 

Indicanuria is not necessarily associated with 
constipation, but is due to pathological conditions 
in the lining of the intestinal tract or of its secre- 
tions. Subacidity may give it. 

Tests for indican (Obermayer's). 

Equal parts of urine and reagent (0.2% solution 
of ferric chloride in fuming HCl). It is best to 
filter out bile pigments with PbSO^ before adding 
reagent. To the urine and reagent add 2 cc of 
chloroform and shake 12 times. Chloroform ex- 
tracts indican (blue), which sinks to the bottom of 
the test tube. KI gives a deep cherry red color with 
the same test. Albumin^ unless present in large 
amounts, does not interfere with the reaction. 
Thymol gives violet red shade, which is obviated 
with sodium thiosulphate. 



38 

VT. Hematoporphyriii. Occurs in uriue in such 
small amounts that it is normally difficult to detect. 
It is an iron-free derivative of hemoglobin. 
Increased amounts occur in: 

1. Certain diseases, rheumatism, phthisis, Addi- 
son's disease, paroxysmal hemoglobinuria, exoph- 
thalmic goiter, lead poisoning, syphilis and other 
diseases. 

2. Use of hypnotics such as trional, veronal, sul- 
pronal and tetronal. 

Test for HematoporiDhyrin. 

Strictly spectoscopic. Take 5 cc of urine and add 
10 cc of 10% XaOH. Filter and to the precipitate 
add 5 to 10 drops of dilute HCl and 15 cc of alcohoL 
Filter and examine the filtrate spectoscopically. 
Abnormal pigments of the urine. 

A. Blood pigments : Hemoglobin, methemoglobin, 
hematin and hematoporphyrin. 

Occurrence : 

I. Hematuria. A condition in which blood as such 
is present in the urine, and is visible with the naked 
eye or with the microscope. The urine is turbid, 
red-tinged, smoky, and sometimes clots are seen. 

Occurrence of hematuria : 

1. General diseases. Yellow fever, typhoid fever, 
smallpox, leukemia, and purpura. 

2. Renal origin: (a) Acute congestion or inflam- 
mation, (b) acute congestion following poisons, (c) 
renal infarction, (d) stone in kidney, (e) tbc. of 
kidney, (f) tumors of kidney, (g) parasites, such as 
filaria and bilharzia. 

8. Genitourinary tract conditions : Passage of 
stone, Dietl's crisis, stone in bladder, tumors of 
bladder, and urethral conditions similar. 

4. Traumatism, o^Derative or accidental. 

5. Renal epistaxis. In this condition sudden 



39 

unexplained liemorrliages occur with no pain. It 
occurs in one or the other kidney and does not lead 
to more serious conditions later on. 

IT. Hemoglobinuria. In this condition the formed 
elements of tlie blood are absent and merely the pig- 
ments are present. The urine is usually clear and 
dark brown. 

Occurrence : 

1. Toxic conditions, following severe burns, expo- 
sure to cold, poisons and fevers. 

2. Essential or paroxysmal type characterized 
clinically by: 

(a) Pronounced hemoglobinuria. 

(b) Aching in the lumbar region. 

(c) Chills, fever and headache. 

This type often follows exposure to cold. In this 
condition the patient's own blood has amboceptor, 
Avhich is capable of uniting with patient's own cor- 
puscles. Cause not known. Majority are spyhilitics, 
acquired or congenitally so. 

Tests for hlood and hemoglobinuria: 

Chemical tests. 

1. Heat and acetic acid test. Brown coagulum 
forms, which tends to float. Decolorized with acid 
alcohol. 

2. Heller's test. Make urine alkaline with sodium 
or ammonium hydroxide, gently warm. A precipi- 
tate of phosphates and carbonates forms, which 
turns brown. 

3. Teichmann's hemin test. To urine add XaOH. 
Filter and wash with water. Dry by pressing be- 
tween filter papers. Fragments of ppt. are placed 
upon glass slide, to which is added a crystal of 
XaCl. Add three drops of glacial acetic acid and 
place cover slip over mixture. Heat gently, do not 



40 

boil, and as acid evaporates replace it. As soon as 
the material becomes brown, allow to cool slowly. 
A positive test shows, microscopically, crystals 
rhomboid in shape and in sheathes. These crystals 
are hyprochlorate of hematin. 
Errors : 1 . Heating too much. 

2. Too rapid cooling. 

3. Excess of NaCl. 
Sensitive in dilution 1 to 100,000 parts. 
Giiiac Test: For blood — 

1. Make fresh tincture of guiac with alcohol; 
should be shade of light yellow ; mix with equal vol- 
ume of ozonized oil of turpentine, or HoOg. 

2. Four or five cc urine, to to 8 drops glacial 
acetic acid ; allow to stand 8 minutes ; extract with 
ether. 

Pour solution 2 upon 1 in such manner as to form 
layer ; a deep blue ring will form if blood is present. 
Benzidine Test for Blood — 

1. Two per cent, alcoholic solution is taken and 
mixed with equal volume ozonized oil of turpentine, 
or H2O2. 

2. Four to five cc urine plus 6 to 8 drops glacial 
acetic acid; let stand 8 minutes and extract with 
ether. 

Stratify 2 upon 1; a greenish ring will form at 
line of contact if blood is present. 

III. McthemogJoljin. Occurs in spontaneous de- 
composition of blood ; also following poisoning by the 
chlorates, nitrates, arsenic, acetanilid, antipyrene. 
sulphonal, turpentine. 

IV. Hematoporpliyrin. See previous discussion. 

B. Bile pigments. Bilirubin is the most frequent. 
Sources of choluria (a) Hepatic origin. 

(b) Hematogenous origin. 



41 



K- 









^- 



o 



I 



^ 

^ 












^ 






^ 









I 






\i- 



42 



Hepatic origin occurs: 

1. Cirrhosis of the liver, 

2. Cancer of the liver. 

3. Obstruction to the biliary passages. 
Hematogenous origin occurs : 

1. AVhere blood pigments are present in ex- 
cess of the mobilizing power of the 
liver, as in pernicious anaemia, ma- 
laria, pneumonia, yellow fever. 
(All jaundice is essentially obstructive in origin.) 
Appearance of the urine in choluria : greenish 
yellow, brown, pure green. * 

Tests for l)ilc' : 

1. Foam test. Shake a specimen of urine which 
produces foam. If bile is present the foam x:)ersists 
and is of yellowish color, ^'ormal urine does not 
produce much foam, and the foam which is produced 
is white in color. 
'2. (xmelin's test. 

Kegent : Strong HNO3 pl^^s HNO,. This can be 
made by boiling con. HNO3, in which is 
placed a match stick, until it takes on a 
yellowish color. 
Method : The urine is layered upon the reagent 
thus made. A positive test shows a green 
ring at the line of contact, and a yellow ring 
slightly above. Below the line of contact 
appear a series of colors ranging from blue 
to red from above downward. 
Errors: 1. Too much NHO,. 

2. Too much albumin. 
:]. Urine containing too much indican. 
4. Urine too concentrated. 
5. Urine containing antipyrene or thymol. These 
drugs can be ruled out satisfactorily. 



43 

Rosenhacli's modification of GmelUi's test. 

Acidif}' urine Avith HCl and filter 4 or 5 times 
through same filter paper. Let paper dry. 
Touch a single drop of HNO, plus HNO, 
solution to the paper. Concentric rings will 
appear, green on the outside. 
Smithes test. 

Make urine acid with 5% acetic acid. Layer 

upon urine 1% alcoholic solution of iodin. 

Bile pigments give emerald green at line of 

contact some time after, which tends to diffuse 

upward. (Kather indefinite test.) 

Nakayama^s test. 

To 5 cc. of urine add from 5 to 10 cc. of 10% 
solution of barium chloride. Kemove ppt. by 
decantation. Treat the ppt. with the follow- 
ing reagent : 

95% alcohol 99 cc. 

Con. HCl 1 cc. 

Ferric chloride .4 gm. 
Bring slowly to a boil. Bile pigments give 
emerald green. If urine changes to green, add 
HNOg and get red color. (Indefinite test.) 
C. Melanin. Normal j)ignient of hair and 
choroid coat of the eye. Pathological increase due 
to over-activity of the cells which form it. 

Occurrence: Melanotic sarcoma, Addison's dis- 
ease, ochronosis and sometimes in malaria. 
Urine is colorless when excreted, but turns 
dark either upon standing or the addition of 
alkaline or oxidizing agent. 



44 
Tests: All three of the following must be posi- 
tive : 

1. Ferric chloride gives black ppt. 

2. Precipitate soluble in sodium carbon- 

ate (black). 

3. Mineral acids plus sodium carbonate 

solution give black ppt. 
D. Alkapton hoclies. When in urine designated 
alkaptonuria. Occurs in people who have an inborn 
hereditary error in metabolism. It is characterized 
by the inability of the body to break up the benzene 
ring. Tyrosin and phenylalanin are changed to 
uroleucin and homogenstic acid. Urine is nor- 
mal in color when voided, but becomes dark on 
standing. Occurs in children Avhose parents are 
lir.>t cousin?. It is a life-long condition, but not 
dangerous. Sometimes victims develop ochronosis. 

E. FJieuoJ do ivatii'cs. These substances consist of 
sulphuric acid in conjugation with phenol para 
cresol, pyrocatechin, and hydroquinone. They are 
excreted mostly in conditions associated with ijutre- 
faction in the intestinal tract or elscAvhere in the 
body. 

Sources: (a) Administration of drugs, (b) Pro- 
tein metabolism. 

F. Diazo compounds, due to alloxyproteic acid. 

Tests : Ehrlicli's Diazo Reaction. 
Reagent : Solution a. Aqueous sol. 

sodium nitrite 0.5 % 

Solution b. Sulphanilic acid 5 grams 

Concentrated HCl 50 cc. 



Water q. s. ad 1000 grams 

1 part of sol. (a) plus 50 parts of sol. (b) plus 

equal vol. of urine. Shake quickly. Add .1 volume of 



45 

NH^OH aud shake quickly. A positive test is a deep- 
red color throughout the urine and a red foam. Red 
foam is the most important. After 12 hours a gran- 
ular greenish precipitate occurs. When doubtful, 
wait for this test. Xaphthalene, opium, chrysarobin 
and otlier drugs may give color quite similar, but 
the foam is not red and no greenish ppt. is obtained. 

Occurrence: The diazo reaction is never found in 
health. It does occur in typhoid fever, where it 
finds its most useful application. It is said to 
occur in the first or second week of the divsease in 
80% of the cases. In case of relapse the test again 
becomes positive. The reaction also occurs in pneu- 
monia, scarlet fever, very frequently in measles be- 
fore the rash, and sometimes in tuberculosis. It 
never occurs in rheumatic fever or meningitis. If 
the test is persistently positive in tuberculosis, it 
indicates a progressive lesion. 

Ehrlich's egg yellow test : This is due to the pres- 
ence of urobilinogen. This test is the same as the 
former, except that after adding the XH^OH the 
urine takes on a yellow color. 

Occurrence : Just prior to the crisis in pneumonia. 

Russo's test: 5 cc. of urine plus 5 drops of 1-1000 
methylene blue. Positive reaction gives emerald 
green color. Blue color is negative. 

-Occurrence: It is said to be negative in miliary 
tb'c and positive in typhoid (Dr. Evans did not find 
it satisfactory). 

Positive reaction said to occur in measles, small 
pox and chronic and suppurative tbc. 

The reaction is said to be negative in varioloid, 
varicella, scarlet fever, miliary tbc, appendicitis and 
malaria. 

G. Medicines. Phenolphthalein, eosin, salol, 
methylene blue, etc. 



46 

H. Chijluria, characterized by the excretion of 
emulsified fat. Uriue varies from cloudy yellow to 
milky appearance. The surface is covered with a 
layer of free fat. 

Causes : 1. Parasitic. Observed in the Far East, 
due to infection by one form of 
filaria. Elephantiasis is often as- 
sociated with it. 
2. Non-parasitic. Etiology unknown. Oc- 
curs spontaneously and intermit- 
tently in people otherwise well. 
Sometimes due to rupture or ob- 
struction of cysterna chyli. 
I. Lipuria. Characterized by the excretion of fat 
in microscopical quantities. 

Causes : 1. Large ingestion of fats. 

2. Extensive bone injuries. 

3. In diabetes. 

4. Frequent in tbc. 

5. After catheterization when oil is used. 

TABLE OF COLOR OF URINE AND ITS CAUSE. 

Yellow and Orange Pink and Red 

Normal Hematuria 

Urobilin Hemoglobinuria 

Choluria Hematoporphyrin 

Medicinal #when alkaline 

Rhubarb # Pyramidon 

Senna # Trional 

Santonin # Sulphonal 

Phenolpbtbalein# Eosin 

Cbrysopbanic ac# Rosanilic acid 

Cascara# 
Brotvn and Black Blue and Green Milky or Whitish 

Choluria Methylene blue Lipuria 

Melanuria Urobilin Chyluria 

Alkaptonuria Phosphates 

Phenol derv's. Bacterial infect. 

"Black Water Fever" Dirty container. 

Indicanuria 
Medicinal 
Salicylic ac 
Salol 
Resorcin 



47 



Optical activity of urine: Xorinally levo-rotatorv 
from .01 to .18 deg. 

Increased : 1 . In excretion of levnlose. 

2. Glycnronic acid excretion. 

3. Albnmin (I/2 gni. per 1000 cc). 

4. Diabetes (B-Oxybutyric acid). 

INORGANIC URINARY CONSTITUENTS. 
The composition of tlie urine depends upon the 
diet of the individual, both in quality and quantity. 
Normally 1200 to 1500 cc. are excreted daily with 
60 to 70 gms. of solids, organic and inorganic. 



Inorganic 


25 


to 30 gms. 


Organic 


35 to 


40 


gms 


NaCl 


10 


to 15 gms. 


Urea 


15 to 


40 


gms 


P205 


1 


to 5 gms. 


Ammonia 


.7 to 


4.27 


gms 


S03 


1 


to 3l^ gms. 


Creatiniii 


1.0 to 


1.5 


gms 


COS 


9 


to ? gms. 


Uric acid 


.5 to 


1.25 


gms 


Na20 


4 


to 714 gms. 


Hippuric acid .7 




gm. 


K20 


2 


to 4 gms. 


Other 








CaO 


.1 


to .3 gm. 


constituent 


s 1.5 to 


2.3 


gms 


MgO 


* .11/^ to .4 gm. 










Fe 


1 


to 11 mg. 










Chlorides. 


The excretion of chlorides 


dep 


ends 



upon the intake in health. 

Source: (a) Vegetable foods in combination with 
K and Ca. 
(b) NaCl seasoning most important 
source. 
Chlorides are taken in order to prevent the ac- 
cumlation of K salts in the blood. There is a 
chloride balance as characteristic as the N bal- 
ance. Increased ingestion of NaCl is followed by 
increased excretion. Chloride poor or free diet gives 
a drop in the excretion to a certain extent, but no 
further. The proportion in the blood is a constant, 
as well as that in the tissues. 



48 

Eetention occurs : 

1. Active stage of all fevers. In pneumonia 

there may be a suppression till the crisis. 
A chloride crisis also occurs. 

2. Formation of transudates and exudates. 

3. Profound and continuous vomiting and 

diarrhoea. 

4. Hyperacidity. 

5. Oedema (myocardial or nephritic). 
Theories of retention. 

1. Histo-retention theory (Strauss -and Loeb) : 

Excess of salts in the tissues requires 
water to maintain osmotic pressure. 

2. Colloidal (Fisher) : In cases of oedema the 

colloids in the tissues have increased 
hydrating capacity. 
Salt excretion: 

1. Following febrile states. 

2. Absorption of transudates and exudates. 

3. Polyuria. 

4. Pneumonic crisis. 

5. FolloAving oedema from salt retention. 

6. After chloroform anaesthesia. 
Quantitative tests: 

1. Volhard's method (1874) : Precipitation of 

chlorides in a known volume of urine by 
an excess of standardized solution of 
Agl^Og in HNO3, and then the titration 
of the excess of AgNOo with NH.SCN, 
using iron ammonia alum as indicator. 
(Objection to method is that it requires 
4 solutions.) 

2. Arnold's method, a modification of the former 

(1885). Differs from the former in the 
strength of the standard solution and fil- 
tration after addition of AgNOg. 



49 

Solutions: 1. AgXOg solution such that 1 cc. 
equals .01 gm. NaCl or 29.075 gm. 
AgNOg in 1000 cc. H^O. 

2. jN^H^SCX solution such that 2 cc. 

equals 1 cc. Ag^S^Og sol. 

3. Saturated solution of iron ammonia 

alum. 

4. Pure HXOo. 
Procedure : 

Uriue 10 ce ^ Pl'^ce in a 100 cc. volumetric flaslv 

' for 10 iniimtes. agitate from time to 

i time. Overcome coloring by 3 to 5 

Std. AgXOs 20 cc. I drops of 10% sol. of potassium per- 

^ mangnate. Add H,0 up to 100 cc. 
H>0 50 cc.) ,„^„ flij^^ 

To 50 cc. of the filtrate add 5 cc. of the iron am- 
monia alum sol. for indicator andi titrate with 
NH^SCN to end reaction, which is red-brown color. 
3. Lutke Martins method (1S92) : 

Solution : A. AgXO.. 17.5 gms. 

2d% HXO3 000.0 cc. 

25% HXO3 equals 225 cc. con. 
XHO3 in 675 cc. of distilled H.O 

10% iron ammonia alum 50.0 cc. 
Water q. s. ad. 1000.0 cc. 

B. X/10 XH.SCX 

Titrate solution A against a X/10 HCl solution. 

In making solution B dissolve 7.6 gm. of XH^SCN 
in less than 1000 cc. of water. Add water till 1 cc. 
of it equals 1 cc. of A, which is determined by 
titration. 

Method of performing determination: 

10 cc. of urine plus 25 cc. of X/10 AgXOg plus 
water q. s. ad 100 cc. Add a few drops of potas- 
sium permangnate to decolorize urine if necessary. 
Allow to stand and filter or draw otf 50 cc. Titrate 
the filtrate with X/10 XH^SCX to the end point, 
using iron ammonia alum as indicator. 



50 

Calculation: Example 6.2 cc. :NV10 NH.SCN to 
produce end reaction. 
2 times 6.2 equals 12.4 cc. AgNOg are uncom- 

bined in 10 cc. of urine. 
25 minus 12.4. equals 12.6 cc. N/10 AgNOg are 

combined as AgCl in 10 cc. 
1 cc. X/10 AgXOg equals .00585 gm. XaCl. 
12.6 times .00585 equals gms. NaCl per 10 cc. 
(10 to 15 gms. per 21 lirs. normal), 
rrinciple : When X/10 XH.SCX is added it com- 
bines with the unused X/10 silver nitrate as long 
as there is any present. When it is all in combi- 
nation with NH^SCX it begins to combine with the 
iron ammonia alum, wliich gives a brown color and 
is the end point in the reaction. 
Purdy's centrifuge method : 

10 cc. of urine, 1 cc. of NHOg and 4 cc. of a 5% 
solution of AgXOg are placed in a special centrifuge 
tube. Agitate and centrifuge at 1200 revolutions 
for three minutes. Eead the number of grams per 
1000 on the scale. 
Bayne-Jones method : 

Either use a special flask or an ordinary 25 cc. 
graduate. In case tlie special flask is used, the 
urine is added to the mark U. Titrate with N/20 
XH^SCN solution to the end point and read grams 
per liter on the scale (iron ammonia alum indi- 
cator). 

In case the 25 cc. graduate is used, add 5 cc. of 
urine and 10 cc. of X/20 AgXOg. Titrate as before 
with X/20 XH.SCX, and note the reading. 



51 . 

Calculation : 

V equals total volume at eud of titratiou. 
Y-15 equals number ec. of N/20 NH^SCN 
V-15 

equals number cc. N/10 AgNO^ uncombined 

2 

Y-15 

10 equals number ec. N/10 AgNOg combined as AgCl 

2 

1 cc. N/10 AgCl equals .00585 gm. NaCl 
V-15 

10 X .00585 equals gm. NaCl in 5 cc. urine 

2 

Y-ls 

10 X .00585 X 200 equals gm. NaCl in 1000 cc. 

2 

20.475 minus .585 Y equals gms. per 1000 cc. 
(.1 to .3 gm. error) 

Phosphates. Excreted as sodium, potassium, cal- 
cium and magnesium salts of HoPO^ as well as with 
glycerin from the breaking down of lecithin. 
Source: 1. Food ingested. 

2. Breaking down of proteins, ingested or 
endogenous. Nucleo-proteins most 
abundant source. 

Amount : 1 to 5 gm. per day expressed in terms 
of P2O5 

Excretion : Depends upon amount taken. Greater 
on alkaline diet. Majority of earthy phosphates 
are excreted in the feces (Ca and Mg). Phosphate 
metabolism is still in a state of uncertainty, for it 
is not known where P2O5 is stored. Bone takes up 
a great amount, but does not account for amount 
ingested. Eatio between N excretion and PgOg is 
P :N : :1 :7. 

Increased : 

1. Animal diet. 

2. Ph^^sical exercise. 

3. Starvation. 

4. Conditions where protein disintegration is 

sroins: on. 



52 



5. Phospliatic diabetes, where urine lias char- 
acteristics of diabetes, but no sugar. There 
is associated with it dryness of the skin 
and excessive thirst. The c-h metabolism 
is not abnormal. 

G. Phosphorous poisoning. 

7. Meningitis and tuberculosis. 

8. Emotional states. 

9. Mental work. 
Decreased : 

1. Vegetable diet. 

2. Certain diseases : 

Addison's disease, 
Hepatic cirrhosis. 
Certain types of nephritis. 
Acute yellow atrophy, 
Chronic lead poisoning, 
Certain types of bone disease. 

3. Pregnancy. 

4. Euns parallel with uric acid excretion in gout. 
Phosphaturia is characterized by the frequent and 

constant excretion of cloudy urine at the time of 
voiding. It is noticed mostly in nervous, sexual 
neurasthenics of the male sex. Noticed also in cyclic 
vomiting of children and hypoacidity. This condi- 
tion represents not a disease, but a condition in 
which the amount of acidity of urine is diminished, 
now called alkalinurin. 

Stilpliates. Excreted in three forms: 

1. Preformed or neutral. 

2. Conjugated or ethereal. 

3. Xeutral, unoxidized or organic. 

Total excretion about 2l^ gm. in 24 hours on a 
mixed diet, expressed in terms of H2S0^. 

Source: Amount in diet relatively small. Most 



53 

of it arises in the destruction of protein. Amount 
excreted increases with increase in protein cata- 
bolism. 

Ethereal sulphates result from the conjugation of 
indol, saktol and phenol ^Yith sulphuric acid, and 
can be taken as a fair estimate of protein decompo- 
sition. 

Occurrence : 

1. Excessive intestinal putrefaction. 

2. Kich protein diet. 

3. Hypoacidity. 

4. Massi\'e pus formation anywhere in body. 
Neutral sulphates : increased in jaundice and cys- 

tinuria. 

Ckirhonates : Yarj with the amount of carbonate 
forming material in the food. Vegetables contain 
organic acids whicJi are easily converted into car- 
bonates. Generally sedimented as CaCOo. 

SocUuin and potassium : Excreted as salts, amount 
determined as XaoO (-1 — Ti/o) and ICO (2 — 4). 

Sources : 

1. NaCl in the food. 

2. Potassium in vegetable foods. 

The excretion is of little significance clinically. 

Calcium and magnesium: Excreted generally as 
phosphates (CaO .1— .3) (MgO .U/2— .4). 

Source : Food, most of it is lost in the feces ; bone 
destruction, diabetes ; excretion is little understood ; 
its significance is increasing. 

Iron : Always present in small amounts. Increased 
in blood destruction, such as fever, malaria, perni- 
cious anameia. In diabetes it runs parallel with 
the sugar output, 2% mg. of iron to 100 grams sugar. 

Heavy metals : Mercury, lead and arsenic found 
pathologically. 



54 
NITROGENOUS BODIES OF URINE. 
Amount normally excreted varies between 10 and 
16 grams a day. Amount excreted depends upon : 

1. Amount of food ingested. 

2. Tissue metabolism. 

In health there is a nitrogen equilibrium, i. e., 
the N. excreted equals the N ingested. In starvation 
a level is reached on the fourth or fifth day, which 
will last three or four weeks. When food is again 
taken the amount of excreted N is less than the 
ingested N. People feel best on from 4 to 6 grams 
of N excretion. 

To determine the N excretion the following factors 
must be taken into consideration: 

1. Total N of food. 

2. Character of food in terms of ability to produce 

alkaline or acid urine. 

3. Age of patient. 

4. Previous state of nutrition. 

5. Previous diet. Previously there should be seven 

days of diet with regulation of : 

a. Diet, 

b. Exercise, 

c. Amount of food intake. 

d. The condition of the intestines. 
iSiitrogen Partition : 

Mixed D. N-free. Mixed. N-free. 

Total N 16 gms. 3.6 gms. 100% lOOfo 

Urea 13.9 2.2 86.87 61.7 

NH3 .7 .42 4.37 11.3 

Uric Acid 12 .09 .75 2.5 

Creatinin 58 ..6 3.63 17.2 

Undetermined.. .7 .29 4.37 7.3 

Urea N represents great bulk of total N output 
in 24 hours. In N free diet, urea N decreases; am- 
monia and creatinin are increased, at expense of 
urea. 



55 
^^itrogcn excretion : 
Physiological — Increased : 

1. On heavy protein intake. 

2. Fonr to 6 days after birth. 

3. Excessive intake of water. 

4. Exercise. 

Decreased on diets rich in fats and carbohy- 
drates. 

Pathological — Increased : 

1. In acute febrile conditions with high fevers. 

There is no relation between the height of 
temperature and the amount of N excreted. 
N balance can be maintained by proper 
diet. 

2. Chills. 

3. Increased respirations. Urea is relatively 

decreased, while ammonia salts, organic 
acids and uric acid are increased. 

4. Toxic conditions, such as cancer, leukemia, 

exophthalmic goiter. 

5. Diabetes mellitus and insipidus. 

6. Absorption of exudates. 

7. JS'ephritis, especially in albuminuria of 

marked degree. 
Decreased : 

1. Convalescence after fever. 

2. Dysentery. 

3. Formation of exudates. 
Methods of N determination. 

Kjeldahl : 

The principle of this method is the oxidization of 
the organic products with the production of sul- 
phates. XH3 plus HoSO^ equals (NHJ^SO^. The 
NH3 is liberated by the addition of strong NaOH 
and is received in a known amount of standard acid. 



5^ 

Procedure : 

luto a pyrex kjeldahl flask place 
Urine 10 cc. 

K2SO4 10 grams or a teaspoonfiil (oxi- 

dizer). 
CUSO4 1 medium-size crystal (caty- 

litic action). 
Con. H2SO4 15 cc. 

Heat gradually to the boiling point and continue 
to boil till the solution takes on an absolutely green 
color, and boil five minutes longer. Allow the solu- 
tion to cool and then add the following : 
Water 250 cc. 

Talcum 2 tablespoonsful. 

40% NaOH 120 cc. This should be added last 
and in such a manner that it 
does not mix with the solu- 
tion. Pour on side of tilted 
flask and it will go to bottom. 

Connect the flask with a distilling apparatus and 
mix the contents by shaking. Either distill 30 min- 
utes or distill over 150 cc. This distillate is re- 
ceived in 25 cc. of N/4 H2SO4 and the excess of acid 
is titrated with N/10 NaOH, using phenolphthalein 
as an indicator. 

1 cc. N/10 H2SO4 equals .0017 grams NH3. 

1 cc. N/4 H2SO4 equals .00425 grams NH.. 

N equals .823 XNH. by weight. 

.00425 X. 823 equals .003497 grams N for each 
cc. of N/4 H2SO,. 

.0017X.823 equals, .0014 grams N for each cc. 
of N/10 H2SO4. 

Folin's method: 

This is a colorimetric test. 1 cc. of urine is put 
through the oxidizing process and received in 



57 

N/HCl. 5 cc. of Nessler's reagent: 

Hgl 10 grams 

KI 5 

NaOn 20 

H.O 100 cc. 
are added. The color of this is compared with a 
standard color made up of 5 cc. of the reagent plus 
1 mg. of N. 
TJrea. 

About 80 to 90% of the total N in a mixed diet 
is excreted in the form of urea. GO to 65% of the 
total N is excreted in the form of urea in an N-free 
diet. From 15 to GO grams, or an average of 30 
grams, are excreted in a mixed diet per day. 

Modes of formation : 

1. NHo salts. (Protein — hydrolTsis — amino acids 

— NH3.) Action of bacteria and enzyme 
action of tissues. 

2. Deamidization method. (Protein — amino acid 

— blood — tissues — protein.) When amino 
acids are in excess NH3 is split off in the 
liver and oxy-organic acids are formed. The 
liver protects the body from NH3 poisoning. 

3. Arginin plus arginase gives urea and or- 

nithin. 

Variations in excretion. 

1, Physiological 1 Increased and decreased same 

2. Pathological J as total N. 

3. Relation of urea to liver function. 

4. Relation of urea to renal function. One can't 

determine the renal function by the esti- 
mation of the urea alone, but one must take 



58 

into consideration the amount of urea in 
the blood. 
5. Kelation of urea to acidosis, formal reac- 
tion of blood alkaline. The fixed alkalinity 
of the blood can't be reduced beyond a cer- 
tain point without certain things happen- 
ing. As an excess of acids is formed^ an 
excessive amount of NH3 salts is formed. 
Urea decreases as output of NHg increases. 
Qualitative tests for urea. (Not used clinically.) 
1. Biuret. Crystals of urea heated to boiling 
give cyanuric acid and biuret. Add CuSO^ 
and XH4OH and get blue color. 
2. Furlurol. 1 to 2 drops of furfurol plus 1 to 2 
drops con. HCl, plus 1 to 2 drops urine. 
Positive test gives dark blue to black color. 
(Quantitative estimation of urea : 
Knop-Hufner method. 

This test relies upon the decomposition of urea 
v\irh sodium hypobromide and the measurement of 
the N evolved. The reaction takes place according 
to this equation : CO(XH2)2 + SNaOBr = 3NaBr -f 
2X + COo -f '2Ii.A\ The COg is absorbed in an ex- 
ce:^s of alkali and the amount of N gas measured. 
Doremus Ureometer. 

The principle of the Knop-Hupfer method is used 
and a graduated ureometer measures the amount 
of gas. 

Solutions : 

1. 20% XaOH. 

2. Bromine. 

When ready to use, add 1 cc. of the bromine to 
40 cc. of the XaOH solution. Fill the ureometer 
tube and add by means of a curved pipet 1 cc. of 
urine to the upright part of the tube. Read grams 
off on the scale. Method unsatisfactory. 



59 

PoUn metJiod. 

The principle of this method is that crystalized 
magnesium chloride boils in its own water of crjs- 
talization at 160 degrees centigrade. If urea he 
present it is decomposed into ammonia and carbon 
dioxide. If acid be present the ammonia formed 
will combine with the acid and can be titrated. 

Urease method (Marshall). 

The principle of this method is this : The soy bean 
extract contains an enzyme capable of splitting urea 
into ammonium carbonate. 

Characteristics of the enzyme : 

1. It is soluble in water. 

2. It reacts quantitatively with urea. It will 

split off a certain amount in a given time 
and no more. 

3. It does not form NHg from any other source 

than urea, and will form NH3 in the pres- 
ence of any other substance, except. (5j. 

4. Its optimum activity is 55 deg. C. 

5. Its activity is destroyed by acids, heavy 

metals and alcohol above 20%. 

6. It has a self-retarding effect. After a cer- 

tain amount of (^2:4)2003 is formed its 
action becomes inhibited. 

Direct method of performing test: 

Test tube A. 10 cc. of urine. 

Test tube B. 10 cc. of urine. 

1 — 2 urease tablets dissolved in water. 
Allow these to stand: 

1. At room temperature over night, or 

2. 45 to 50 deg. C for 1 hour, or 

3. 37 deg. C. for 3 hours. 

Titrate both tubes for alkalinity, using methyl 
orange as an indicator. 



60 

Subtract the no. of cc. used in titrating A from 
the no. used in titrating B. 1 cc. of N/10 HCl 
equals .003 grams of urea or .0014 grams X. 

The disadvantage of the test is that the whole 
solution becomes clouded and the end reaction is an 
(obscure one. 

Indirect method. 

Test tube A. 5 cc. of urine. 

Aqueous solution of 1 or 2 urease tablets. 
A layer of kerosene to prevent foaming. 
Stopper and allow to stand as before. 
Test tube B. 25 cc. of X/10 HCl. 
2 drops of 1% sol. alizarin, 
A layer of kerosene. 
After tube A has stood its proper length of time, 
connect it up to a suction apparatus in such a way 
that the indrawn air first passes through a solution 
of HgSOi. Allow air to be drawn through for about 
a minute in order to remove any free ammonia that 
may be present. Now, connect tubes A and B in 
such a way that the air current passes from A into 
P. When this has been done, add a teaspoonful 
of dry potassium carbonate to tube A, quickh^ cork, 
shake and start suction apparatus. Allow air cur- 
rent to pass from A into B for about 30 minutes. 
The ammonia in A is freed and caught in the N/10 
HCl in B. Titrate the excess of HCl in B with 
X/10 XaOH. 

Subtract the number of cc' s necessary to bring 
about the end reaction from 25 cc, the amount of 
X/10 HCl originally added. Repeat this process, 
using 5 cc of urine to which no urease solution is 
added. This gives the preformed ammonia. This 
value subtracted from the former gives the amount 
of XHo formed from urea. 

Make the calculation of the amount of urea on 



6.1 
the basis of: 1 cc. of X/10 HCl equals .003 grams 
of urea or .0014 grams X. 
ZJiic acid. 
Amount : 

.2 to 2.0 grams per day. 
Mixed diet .37 gm. or .8% total X. 
N-free diet .09 gm. or 2.5% total X. 
Origin. 

Uric acid is not a product of protein decomposi- 
tion. 
Xucleo-protein plus pepsin, trypsin, etc., gives 

nucleic acid and protein. 
Xucleic acid plus tetranuclease gives purin and 

' pyrimidin dinucleotide. 
Purin nucleotide plus pliosplio-nuclease and 
purin nuclease give: the former, adenosin 
and guanosin ; the latter, adenin and guanin. 
Adenin plus adenase gives hypoxanthin. 
Guanine plus guanase gives xanthin. 
Adenosin plus adenosin deaminase and guanosin 
plus guanosin deaminase give xanthin and 
inosin, which when the c-h radical is split off 
give xanthin and hypoxanthin. 
Xanthin and hypoxanthin plus xanthin oxi- 
dase (liver) gives uric acid. 
Sources of uric acid : 

1. Exogenous. The greater portion of nucleic 

acid comes from the diet : sweet bread, liver, 
caiTein and theobromin. 

2. Endogenous. 

a. Breaking down of tissue nuclei. 

b. Purin bases free in the body. 

3. Synthesis. There is no evidence that this 

occurs in man, but it does occur in birds. 
Uric acid destruction in the body. 
In birds it is .destroyed by ferments and allan- 
toin is the excretory product. 



62 
The following facts are known : 

1. Uric acid fed can be recovered quantitatively 

in the urine. 

2. Endogenous purine metabolism in persons on 

an N-free diet is constant. 

3. Uric acid can be broken down by other routes 
than allantoin. 

a. Glycocoll. 

b. Oxalic acid-urea. 

c. Persons fed on purin bases excrete 

half in the form of urea. Purin 
bodies can be excreted in forms not 
going through the uric acid s'tage. 

4. When uric acid reaches the system it is ex- 

creted as such. 

C/haracteristic properties of uric acid. 

In the cold it is sparingly soluble in H2O 
(1 — 40,000). It is fairly soluble in blood serum 
(1 — 1,000). Its best solvent is a solution of urea. 
It is insoluble in alcohol, ether, chloroform and 
acetic acid. It is somewhat soluble in HCl, II2SO4 
and weak alkalines. Solutions of uric acid in water 
are neutral to litmus. Uric acid in sufficient con- 
centration reduces Fehling's solution, but not 
Nylander's. Uric acid is kept in solution under the 
following conditions : 

1. With neutral phosphates. 

2. When pigments are present. 

3. As neutral urates. 

4. As monosodium or biurate — 

Ammonium biurate (urinary type of sedi- 
ment). 

Sodium biurate (gout). 
Excretion of uric acid. 



63 
Increased : 

1. Purin or meat rich diets. 

2. Increased protein decomposition. 

3. When lencocvtosis is predominant feature in 

leucaemia, especially when treated with 
X-ray. From 12 to 15 gms. per day is 
sometimes excreted. 

4. Pernicious anaemia. (In secondary anaemia 

less than normal.) 

5. Articular rheumatism and after medication 

with salicylates, atophan, colchicum and 
urotropin. 
Decreased : 

1. Vegetable diet. 

2. Certain types of chronic nephritis. 

3. Chronic lead poisoning (diagnostic). 

4. Quinine and opium. 

Uric acid in relation to gout : All theories have 
fared badly. 

1. In cases of chronic gout the excretion of uric 

acid upon a given diet will be the same as 
in normal individtials on the same diet in 
most cases. 

2. The excretion of uric acid in chronic gouty in- 

dividuals persists in being lower than normal. 

3. Gout}' patients fed with purin bases will show 

a lower curve of uric acid excretion than 
normal. 

4. On a purin free diet gotity patients will show 

a lower endogenous excretion than normal. 

5. The blood of gouty patients contains more uric 

acid than normal, 4 to 5 mg. instead of 1 mg. 

6. The elimination of uric acid is less than normal 

from 1 to 3 days preceding an acute gouty 
attack. 

7. With the start of the acute symptoms there is 

a rise of the excretion above normal which 



64 

lasts for three or four days, and then is fol- 
lowed by a much lower output than normal. 
8. The relation between an excess of uric acid in 
the blood and in the urine in acute gouty 
manifestations is not known. 

0. Gouty individuals show utter abnormal condi- 

tions of metabolism. 

10. Probable explanation of gout is that gouty 
individuals do not possess necessary uric acid 
elimination and certain tissues seem to pos- 
sess an aflfinity for uric acid. 

Factors modifying uric acid excretion. 

1. Diet. 

2. Tissue metabolism. 

3. Indeterminate amount of free purin bases. 

4. Amount of conversion of uric acid into urea. 

5. Amount of uric acid destruction in the body. 

6. How much synthesis occurs. 

7. Varyino: degree of blood retention. 

8. Kenal capacity of eliminating uric acid. 

9. Amount of urinary phosphates. 

10. Degree of urinary concentration. 

11. Akalinity of urine. 
Quantitative uric acid determination. 

Folin method : 

Urine 300 cc. 

Folin's reagent To* cc. 

(gives precititate of phosphates) 
Folin's reagent : 

Am. Sulph. 500 gm. 

Uranium acetate 5 gm. 
10% acetic 60 cc. 

H2O q. s. ad. 1,000 cc. 

Wait 15 minutes and filter. Place 125 cc. of the 
filtrate (which equals 100 cc. of urine) in an Ehrle- 
meyer flask. Add 5 cc. of concentrated XH^OHj let 



65 



stand 24 hours and filter. Collect the precipitate of 
ainmoniiTiTi urate, wash it with ammonium sulphate 
until the filtrate no longer shows a reaction with 
AgXOo, pierce the filter paper and wash the precipi- 
tate into a breaker Avitli 100 cc. of water. Add 15 
cc. of con. HoSOj, lieat over a fiame, and while still 
hot titrate witli N/20 potassium xjermanganate 
(1.5(>7 gn?. in 100 cc. ) to end point, Avhich is a red- 
dish blush for from 15 to 30 seconds. 

Calculation : 1 cc. of X/20 potassium permanga- 
nate equals 3.75 mg. of uric acid. (Uric acid has 
the proi)erty of reducing i^otassium permanganate.) 

Correction: ]"or each 100 cc. of urine add 3mg. of 
uric acid, for a certain amount of urate is soluble 
and does not change into uric acid. 

Aiiiinoiiia : De])en<l> upon protein, intake and runs 
parallel with X excretion. On a mixed diet about 
.7 gms. are excreted in 24 hours or 4.37% of the 
total N, and upon an N-free diet about .42 gm. or 
11.3% of the total N is excreted. 

Increased : 

1. Decreased oxidation. 

2. Acute febrile conditions. 

3. Liver diseases. 

4. Uraemia. 

5. Toxic vomiting of pregnancy. 

6. Diabetes, characteristicalh' abnormal. 

7. Starvation. 

8. Chloroform poisoning. 
Decreased : 

1. Xephritis. 

2. Most akaline therapy. 

3. Conditions with Ioav HCl. 

XHo elimination is associated with acidosis. In 
this condition one finds : 1. Increase of acids with 
formation of neutral salts. 2. Lowered blood and 



66 

tissue alkalinity. 3. Carrying capacity of the blood 
for CO, lowered and CO2 accumulates in the tissues 
(tissue asphyxia). 4. Increase in the H concentra- 
tion of the blood stimulates the respiratory center 
and air-hunger results. 
Occurrence of acidosis : 

1. Diseases with clinical symptonis. 
Diabetic acidosis. 

Acute nephritis and acute diseases associated 
A\ith nephritis. 

In late stages of primary and secondary con- 
tracted kindey. 

Food intoxication of children. 

Atrophic cirrhosis. 

2. Diseases without clinical symptoms. 
Acute febrile conditions. 
Advanced cachexia. 

Severe anaemia. 

After general anaesthesia. 

Cardiac conditions. 
Quantitative ammonia determination. 

Schlosing method : 
The objection to this method is that the results 
are too high. 

Folin's method : 

10 to 20 cc. of urine are introduced into an aerat- 
ing cylinder and a layer of kerosene added to reduce 
tlie tendency to foam. The apparatus is connected 
with a flask containing a knoAvn quantity of X/10 
HoSO^ (20 cc.) and sufficient water to well cover 
tlie absorption tube. About one gram of sodium 
carbonate is added to the urine and the ammonia 
liberated is aspirated by means of a suction pump 
into the known acid solution. The current of air 
should first pass through a dilute £[280^ solution 
in order to absorb any ammonia that may be x)resent 



67 

in the indrawn air. Aerate for one hour and titrate 
the excess of acid Avith X/10 NaOH, using methyl 
orange or alizarin as indicator.. 
1 cc. of N/10 H.SO, equals .0017 grams of XH.. 

or .0014 grams of X. 

Ci'catiu'ui : About .50 gm., or 3.0% of the total X, 
is excreted upon a mixed diet, and about .0 gm., or 
17.2% of the total X, is excreted on an X-free diet. 
It is an anhydride of creatin, but the relationship 
between tiie two is not clear. Creatin probably 
comes from arginin, and creatinin is formed by the 
action of anliATlrating ferments. There is a remark- 
ably constant excretion of creatin irrespective of 
the X intake. Folin considers creatinin a valuable 
index of protein metabolism, while Shaffer thinks 
it an index of some special i)rocess of normal meta- 
bolism occurring mostly in muscles. 

Exogenous elimination depends upon the ingestion 
of meats. 

Endogenous elimination has the following char- 
acteristics : 

1. Constant on X-free diet. 

2. Varies with different individuals. 

o. Apparently independent of total X metabolism - 
J:. Depends upon weight of individual. 

A normal individual excretes from 7 to 12 mg. 
per kilo in 21: hours. 

Source: Largely due to muscle metabolism of the 
body. It is, however, formed in other than muscle 
tissue. There is a diminished excretion in anaemia, 
marasmus, myositis ossificans, chlorosis, phthisis, 
chr. diffuse nephritis, progressive muscular atrophy, 
and pseudohypertrophic paralysis. It is said to be 
increased in the acute stages of some fevers and 
exophthalmic goiter. The X excretion runs more or 
less parallel with protein decomposition, but creati- 



6S 

nin does not. Tlie liver is one main source of forma- 
tion. 

Qualitative tests for creatinin. 

JaftVs test: 
To urine add picric acid and dilute NaOH (10%), 
which turns a brilliant sliade of red and which be- 
comes darker on standing. Upon the addition of 
acetic acid it changes to an ochre color. 
Weyl's test : 
To urine add nitroprussid of soda and a few drops 
of 10% XaOH. A deep red orange or ruby color 
appears, which, upon the addition of a little glacial 
acetic acid, turns to green and upon heating to Ber- 
lin blue. 

Quantitative determination. 

Folin method (colorimetric) : 
A standard solution is made up by the following 
method : One gram of pure creatinin is dissolved in 
1000 cc. of water. 1 cc. of this plus 20 cc. picric add 
plus 1.5 cc. of 10% NaOH plus enough- water" to 
make 100 cc. gives the standard color. 

One cubic centimeter is treated in the same man- 
ner, and the resulting color is compared with the 
standard solution by means of a colorimeter. 
Undetermined Nitrogen. 

Mixed diet .7 grams or 4:.31% 
X-free diet .29 grams or 7.3 % 
This is determined by subtracting the sum of the 
other forms of N from the total N. 
Source : 

1. Amino acids which are known to be excreted. 
Tyrosin, leucin, giycocoll (1^-2 grams per 
day). In cystinuria there is a perverted 
metabolism to amino acid; 181 such cases 
have been reported. These patients do not 
have the power to reduce the amino acids 



69 

further than cvstiii. Gystin calculi fre- 
quently form. A marked hereditary ten- 
dency prevails in this disease in which 
males are more frequently effected than 
females. In diaminouria putrescin and 
cadaverine are excreted. 

2. Hippuric acid. 0.1 to 1 gram per day. Ben- 

zoic acid foods, such as fruit, berries, 
prunes, etc., combine with giycocoll. 

3. Oxyproteic acid 1 These are responsible for 
Alloxyproteic acid J Ehrlich's diazo reaction. 

Their excretion is probably increased in 
cancer. They contain an S mollecule. 

4. Allantoin. This is normally present only in 

traces. It exists normally and abnormally 
in conditions little understood. 

REDUCING BODIES OF THE URINE. 

Subjects to be considered : 

1. General review of carbohydrates. 

2. Qualitative determination of glucose. 

3. Sugars and reducing bodies other than glucose. 

4. Quantitative determination of sugar. 

5. Scheme for running down reducing sub- 

stances in urine. 

6. Acid bodies. 

7. Diabetes. 

Carbohydrates. 

The available carbohydrates of the body exist as 
glycogen, which is stored in the liver and muscle 
tissues until called upon b}^ the tissues for energy, 
heat and tissue formation. Sugar is constantly being 
converted by the liver into glycogen and back again 
into sugar in accordance to the body needs. The 
balance between these two in health is such that 
the percentage in the blood is from .1 to .15%. 



70 

Origin of carbohydrates : 

1. Sugars and starches. 

2. Proteins and amine acid bodies. 
?>. Fats. 

Function of carbohydrates : 

1. Energy. 

2. Heat. "^ 

B. Protecting agency for protein. 

4. When in excess forms fats. 

5. Actual synthesis of tissues (nucleic acid). 

Kegulation : 

1. Supply (glycogenetic function). 

2. Storage ( glycogenesis ) . 

3. Tissue consumption (glycolysis). 

When any one of these breaks down glycosuria 
may result, also in cases of renal permeability for 
carbohydrates (renal diabetes and phloridzin dia- 
betes). 

Tlie adrenal and pancreas are antagonistic in func- 
tion. In health the two are in perfect equilibrium, 
but in diabetes the restraint is removed from the 
liver. The i)ancreas also seems to give off some- 
thing to the tissues T\iiich enables them to burn 
carboliydrates to COg and HgO. In diabetes this 
falls short and sugar is eliminated through the 
kidneys, due to its accumulation in the blood. 

A'^ormal urine contains a small amount of glucose 
(animal gum or isomaltose). It amounts to about 
.3 to .G grams in 24 hours. Glycuronic acid occurs 
in amounts of about .004 grams in 100 cc. Traces 
of pentose occur occasionally after the ingestion of 
fruits. Lactose and galactose occur frequently in 
sucklings. 



71 

Assimulation limit for carbohyrates (two kinds) : 
.1. Individuals who show sugar after the inges- 
tion of large amounts of starch (glyco- 
suria ex amylo). 
2. Individuals excreting sugar following sugar 
intake (glycosuria e saccharo). A normal 
individual can take as much as 150 to 200 
grams of glucose on an empty stomach 
without showing glucose in the urine. Per- 
sons with nephritis have a lower sugar 
threshold. The liver has the greatest toler- 
ance for glucose and least tolerance for 
lactose and galactose. Maltose, levulose 
and saccharose come in the intermediate 
group. 
Hamman's method of making threshold test : 
From 150 to 200 grams of dextrose are dissolved 
in 150 cc. of watei^ and flavored with lemon or 
orange juice. The mixture is made ice-cold with 
cracked ice and the volume made up to 300 cc. This 
is taken slowly on a fasting stomach and the blood 
and urine sugar are followed together, the blood 
being withdrawn at 1, 2, 3, 1 and 5 hours after 
taking and the urine being examined at the same 

time. 

Alimentary i^lycosiiria • 



Food — Intestines — Liver 



Hyperglycaemia — Glycosuria 



Diabetic Glycosuria 



Glycosuria C. N. S. — Adrenal 

. ' ' ' 

Sugar accumu- 
lation in blood 

1 
Tissues 

I 

^— Pancreas impairment 



— -Liver — Epinepliriu 

I 

I 



These condition 
can occur under 
nervous excite- 
ment, fear, anx- 
iety and diabetes. 



72 

QuaJitativG test for glucose. 

Trommer's test: 

To 2 parts of urine add 1 part of 10% :N'aOH. 
To this add 10% solution of CuSOl till a bluish 
precipitate results and remains after shaking (add 
the CuSO^ drop by drop). Warm the solution 
(do not boil), and in the presence of sugar a red- 
dish or yellowish precipitate will form, spreading 
graduall}' downward and leaving a decolorized su- 
]3ernatent liquid. 

Reaction : 

H2O + XaOH + 1 drop CuSO, = Cu ( OH) ^ 
CuSO, + 2NaOH = :\X.SO, + Cu(0H)2 
Cu(0H)2 + heat = CuO (black) + H.O 
2CuO + sugar + heat — reduction 
Yellow = CU2OH (alkalinity low) 
Red = CuoO (alkalinity high) 

l^he color depends upon the degree of alkalinity. 
Uric acid, creatinin glycuronic acid, albumin, allan- 
toin, mucin, lactose, maltose and alkapton have the 
propert}^ of holding Cu(0H)2 in solution and reduce 
it to lower salts by heating. A false reduction by 
these substances can be avoided by warming and 
not boiling, for these substances reduce only upon 
boiling, and it tends to occur on cooling. They 
give a dirty yellowish green color to the previous 
blue solution. Dilute urine for more accurate de- 
termination. 

Requirements necessary for positive reaction: 

1. Prompt formation of a precipitate on warm- 

ing, settling to the bottom and leaving a 
clear solution above, before cooling. 

2. Avoid adding CuSO^ to excess, which gives 

black j)recipitate and masks reaction. 



7^ 



P*. Any discoloration after prolonged boiling 

should be neglected. 
4. Albumin 'should be removed before perform- 
ing test if it is present in large amounts. 
Qualitative tests for sugar. 
Fehling's test : 

Solution A. CuSO, 34.65 gm. 

H2O qs. ad. 1000 cc. 



Solution B. 



Rochelle salts 173 gm. 



NaOH 50 

H2O qs. ad. 1000 cc. 

Equal parts of solution A and B are mixed, which 
gives a clear blue solution. Boil mixture in a test 
tube and add urine not over 1/2 by volume. Sugar 
gives reduction in from 5 to 10 seconds. If no re- 
duction occurs, bring the solution back to boil. 
Prolonged boiling gives misleading results. Sensi- 
tive to .08%. 

Errors : Normal Constituents — Uric acid, crea- 
tinin, blood pigments, giycuronic acid and phenol 
derivatives ; also reduced by chloroform and formal- 
dehyde. Drugs — Trional, sulphonal, camphor, mor- 
phia, salicylates, benzoic acid, antipyrene and phe- 
nacetine. 



Benedict's test. 

Benedict's solution : 
CuSO, 

Sodium citrate 
Sodium carbonate 
HoO qs. ad. 



17.3 gm. 
173.0 gm. 

200.0 gm. (crystals) 
1000.0 cc. 

Method of preparing: Sodium citrate and sodium 
carbonate crystals are dissolved in 700 cc. of hot 
Wiiter. Filter while hot and add a proper amount 
of solution of CuSO^ to make 1000 cc. This solu- 
tion is permanently stable, lasting 5 to 10 years, 



74 

and the test is more delicate than Fehling's. Sensi- 
tive to .02— .05%. 

Technique of the test : To 5 cc. of the reagent add 
5 dro]>s of urine. Boil vigorously for 2 or 3 minutes 
and let cool spontaneously. A positive reaction is 
indicated by a reddish or reddisli yellow precipitate. 
If less than ."*% is present a positive reaction is 
likely to occur only as the solution cools. In the 
absence of sugar the solution remains clear or slight- 
ly turbid. It is not reduced by normal urinary con- 
stituent?. 

Haine's test. Same as former, except that sodium 
carbonate is replaced by glycerin. Xot as sensitive 
as Benedict's. 

Xylander's test. Copper is replaced by bismuth 
subnitrate. 

Solution : 

Bismuth subnitrate 2 gm. 
10% NaOH 100 cc 

Rochelle salts 4 gm. 

Keep solution in a brown bottle and don't expose 
to light. 

Technique of test: To 9 parts of urine add 1 part 
of reagent. Put in water bath for 5 minutes ; boiling 
is ijermissible. A positive test is indicated by a 
black ])recipitate of bismuth. In urine with only 
a small percentage of sugar the precipitate takes 
on more of a brownish color somewhat darker at 
the bottom. 

Advantages of the test : It is not reduced by nor- 
mal urinary constituents or alkapton. 

Disadvantages of test: It is reduced by hexoses, 
pentose, glycuronic acid, marked indicanuria and 
urobilinuria. It is also reduced by sulphonal, trional, 
rhubarb, senna, cascara and large doses of urotropin 
and quinine. 



75 

Galactose. 

Conditions which show galactose in the urine: 

1. Infants nursing at breast and having gastro- 

intestinal disturbance. 

2. Used in test for hepatic function (formerly). 
Disaccharides : 

1. Lactose, which splits up into I ^, , ,^ 

J Galactose 

2, Maltose, which splits up into I „, 



3. Saccharose, which splits up into 



I Levulose 
) Glucose 



Lactose : 

Physiologically it occurs during the puerperium 
and sometimes throughout the period of nursing. 
It also occurs in persons on an exclusive milk diet. 
The tolerance for it is low, 80 to 100 grams. It 
never occurs in diabetes. It does not ferment with 
yeast unless it is first broken down to glucose and 
galactose by ferments or bacteria, the former of 
which is fermentable by yeast. To obtain osazones 
the urine should be evaporated down in order to 
make it more concentrated, extracted with an alco- 
hol, evaporate extract, take up in a small amount 
of water and apply phenylhydrazine test. Their 
melting point is 200 degrees. 

Kubner's test for lactose: To from 5 to 8 cc. of 
urine add a large excess of basic lead acetate, boil 
several minutes and filter. To the filtrate add 
XHIrOII till a precipitate forms, redissolves and a 
permanent precipitate recurs, which is a brick red 
color. The filtrate also takes on a reddish color. 
A red solution with a yellow precipitate indicates 
glucose. Lactose is to be expected in urines giving 
slow reduction and D rotatory. 



76 

JfaUosr. 

There are ouly a I'eAN' cases ou record of its occur- 
rence in the urine. It is associated with interstitial 
lesions in the pancreas. It should be suspected in 
urine when rotation is greatly in excess of the 
amount of sugar present, which is determined by 
titration. To determine its presence, hydrolyze the 
urine for one hour with dilute acid. Neutralize and 
test by titration and with polarimeter. 

Saccharose. 

This sugar is hot known in pathological condi- 
tionr*. Chronic maligners often put this sugar in 
the urine in order to get into a hospital for the 
winter. The urine usually has a high specific grav- 
ity, and is of a syrupy nature. Hydrolyze for an 
hour with ^^eak acid. Neutralize with Xa2C03, 
titrate and polarize. 

Fcn)t€)itatio)i : 

It is said that only those sugars which have 3 or 
a multiple of o carbon atoms will ferment, which 
fact does not hold good, only 2 fermentable sugars 
occurs in urine — glucose most frequent, levulose 
next. 

I'cchniquc: 

Controls, 

1. Normal urine -j- yeast = O 

2. Normal urine + yeast -\- dextrose = positive 

3. Specimen of urine alone = O 

Test. 

4. Specimen of urine -|- yeast = -\- according to presence 

of sugar. 

Do not mix by violent shaking Avhen adding yeast, 
and thus admit small bubble?. No. 3 can be omitted 
by first boiling No. -1 . Allow to stand for from 3 to 
I hours at 371/4 degrees. Sensitive from .1 to .05%. 

Phenylhydrazine test : 

Given by all hexoses, pentoses, glucose, levulose 



iiiul iiiaiiuose, but tlie melting point of the ciystals 
is different. 
Teclmiqne: 

l^lienylliydnizine 5 drops 

Urine 4 cc. 

Clacial acetic 0.5 cc. 

Boil and shake 2 minutes, and while still warm 
add 4 to 6 drops of 20% NaOH. Do not add enough 
to make alkaline. Boil from 30 seconds to one min- 
ute longer. Cool spontaneously. If sugar be pres- 
ent the solution will become turbid and deposit a 
yelloAv precitate which indicates crj^stals of osazone. 
This test is extremely sensitive and is the court of 
last appeal for the determination of a sugar. The 
crystals have a characteristic appearance arranged 
in sheathes. To purify the crystals the filter paper 
is punctured and the precipitate washed into a 
theater containing 60% alcohol. Heat and dissolve 
•the crystals; evaporate down and crystals reappear. 
Repeat several times. The crystals are insoluble 
in chloroform, water and ether. They are slightly 
soluble in absolute alcohol, fairly soluble in hot gla- 
cial acetic acid, but best solvent in 60% alcohol. Uric 
acid, ghxuronic acid, oxalic acid and acetone may 
give positive tests. This test should not be done 
on a urine containing albumin. 




Dextrosazone 



78 
Monosaccharides. 
Glucose, levulose and galactose. 
Leviilosuria. 

There are 3 cliuical groups. 

1. Alimentary. 100 grams is the normal limit 

of tolerance. Churchman (See J. H. H. 
Bui.) found that 26% of normal persons 
show levulosuria in 100 grams of the sugar, 
while some patients with actual hepatic 
disease do not. Churchman's conclusions 
on the Strause levulose liver test are: 

1. The test is modified by extrahepatic fac- 

tors of sugar metabolism (renal, adrenal 
and pancreatic complications). 

2. There are difficulties in the test (nausea 

and vomiting ) . 

3. The clinical value of the test is insufficient 

to warrant its continuance. 

2. Diabetic. A good many diabetics have a 

tolerance for levulose. The occurrence of 
levulosuria constantly with glucose indi 
cates a rather serious prognosis. It also 
gives an error in calculating the glucose 
excretion. 

3. Idiopathic. There are only 8 of these cases 

reported in the literature. Those patients 
who show continual levulosuria generally 
have some complication in the glands of 
internal secretion. Three of the cases re- 
ported had hypophj^seal trouble and others 
had trouble with gonads. 
Seliwanoff's test for levulose : 

Urine 10 cc. 

Concentrated HCl 5 cc. 
Kesorcin few Xls. 

Bring the solution to a boil or put in boiling watei 



79 

for .')() secoiul>'. First a reddish blush a])pears, and 
upon standing and allowed to cool a granular red- 
dish precipitate forms. Mannose, maltose and glu- 
cose in large amounts will give the test, also. 
Pentosuria. Kinds : 

1. Alimentary. Follows heavy ingestion of pen- 

tose containing food, such as apples, plums, 
cherries, etc. It probably occurs more fre- 
quently than recognized. It is character- 
ized by optically active xylose and arabi- 
nose. 

2. Diabetic. Frequent in severe types. It is 

characterized by L xylose, Avhich probably 
comes from broken-down pancreatic nucleo- 
protein. 

3. Essential or ideopathic (Dr. Janeway, Am. J. 

Med, Sci., Sept., 1906). 

Features : 

1. Constant excretion irrespective of the diet. 

2. Hereditary tendency. 

3. Patients excrete it for long periods without 

evil effect. 

4. Sugar excreted in this disease optically inac^ 

five. 

5. Amount excreted is usually small (.2 to .6%). 

One case with 1% reported. 
C). Specific gravity somewhat increased. 

7. Amount of urine not excessive. 

8. Acidity high. 

9. Pentoses fed come through in the urine as 

such. 

10. Pentose may be formed from glucose, but 

not determined. 

11. Glycuronic acid excretion continues as 

normal. 



80 
Tests for pentose. 

Phloroglucin (Tollen's). To urine add a small 
amount of HCl saturated with phroglucin. Heat in 
water bath. A deep-red color indicates a positive 
reaction. Watch for the initial shade of red to 
appear and then cease heating. AVhen extracted 
with aniyl alcohol and examined spectroscopically a 
band is seen between D and E. 

Errors : Test given also hj lactose, galactose and 
glycuronic acid. 

Orcin. To urine add HCl and a few crystals of 
orcin. Heat in water bath. The development of 
a green color and the formation of a greenish pre- 
cipitate indicates a positive test. Extracted with 
amyl alcohol gives a band betAveen C and D. 

Bial's method : 

Solution : 30% HCl 300 cc. 

10% Ferric chloride 30 drops 
Orcin 1 gm. 

About 4 or 5 cc. of this solution are heated to 
boiling, and urine is added drop by drop (not over 
1 cc). A positive reaction is indicated by a clear 
emerald green color. This test is best of the three. 

Glycuronic acid. 

Glycuronic acid is an oxidation product of sugar 
metabolism and is not concerned with protein meta- 
bolism. It is not a forerunner of diabetes and does 
not represent anything but detoxication. Its osazone 
has the loAvest melting point of any met with. It 
has an aldehyde group, which accounts for its reduc- 
ing properties. Pure glycuronic acid is dextro-rota- 
tory. 

Test for gl^^curonic acid (Tollen's) : 

To 5 cc. of urine add % cc. of 1% alcoholic solu- 
tion;of naphthoresorcin and 5 cc. of con. HCl. Put 
in water bath and allow to stand 15 minutes. Allow 



81 

to cool at room temperature for -L minutes, and then 
cool under tap. Add ether, which extracts a blue- 
violet color, indicating a positive test. Examined 
spectroscopically, an absorption band occurs at b, 
but is not specific. 

Clinical significance : 

1. Glycuronic acid combines with toxic sub- 

stances and appears in the urine as glycu- 
ronates. Glycuronic acid combines readily 
with the coal tar products, morphin, 
cocain, etc. ; therefore, after such medica- 
tion lools: for glycuronates in the urine. 

2. Copper and bismuth reduction absent or 

atypical. 

3. No fermentation occurs. 

4. Glycuronates in fi'esh urine are levo-rotatory, 

and osazones are formed with difficultv 
(m.p = 114 to 115 deg.). 

5. They are easily confused with pentoses be 

cause reactions are same, but can be differ^ 
entiated by optical activity, glycuronates 
being levo-rotatory and after hydrolysis 
become dextro-rotatorv. 



82 
SCHEME FOR DETECTION OF AN UNKNOWN 
REDUCING BODY IN THE URINE. 
I. Feliling's test: 

A. Negative, no sugar present. 

B. Positive, proceed with 
II. Njlander's test: 

A. Negative, eliminates confusing substances 

in I. 

B. Positive, sugar is probably present, so 

proceed with 

III. Fermentation test: 

A. Positive, sugar present may be glucose or 

levulose. 

B. Negative, reducing substance may be: 

Lactose, maltose, saccharose, pentose, 
glycuronic acid. These become positive 
with hydrolysis. 

IV. Polariscopic examination : 

A. No. I, II and III positive: 

Urine D-rotatory : indicates glucose. 
Urine L-rotatory : indicates levulose. 

B. No. 1, II positive and III negative : 

Urine D-rotatory indicates: Lactose 
maltose, saccharose, alimentary f^en- 
tosuria. 
Urine inactive indicates pentose. 
Urine L-rotatory indicates glycuronic 
acid. 
V. Phenylhydrazine : 

A. Osazones easily obtained with dextrose, 

levulose, pentose, maltose. 

B. Osazones obtained only by special proce- 

dure with lactose. 

C. Osazones obtained after hydrolysis with 

glycuronic acid or saccharose. 



83 

Glycuronic acid osazones have melting point of 
114 to 115 degrees. 

Pentose osazones have melting point of 156 to 160 
degrees. 

Eemaining osazones have melting point of 200 to 
205 degrees. 



84 

QUAXTITATIYE DETEKMIXATIOX OF SUGAE. 

Urinary output and specific gravity. (Xaimyn.) 

This method is inaccurate, but in the absence of 

other means gives some information as to the 

amount present. 

Amount of Urine. Specific Gravity. % of Sugar. 

2000 cc. 102S to 1030 2 to 3% 

3000 cc. 1028 to 1032 3 to 5% 

5000 cc. 1030 to 1035 5 to 7% 

G to 10.000 1030 to 1012 G to 10% 

^'/K'(:•//fc gravity-icrincntation method. 

This method is based upon the principle that 
fermentation by yeast results in lowering the specific 
gravity. A small amount of albumin can be neglected 
and the urine should be acid in reaction; if not 
so, make acid with acetic. 

Technique: 50 cc. of a 21-hour specimen of urine 
are taken and the specific gravity is determined. 
Add 2 cc. of a thick yeast emulsion and allow to 
stand from 21 to IS hours at 37 deg. C, until the 
reduction test is negative. Again make specific 
gravity determination. The ditference between the 
first and second determination multiplied by 231 
coetiicient equals the per cent of glucose. This 
metliod is accurate to .1%, but sugar present should 
not be less than .5%. 

Fermentation metliod. 

A. Einhorn's method. Mix a sufficient quantity 
of urine to fill the special fermentation tube with 
a piece of yeast the size of a pea. Incubate for 
21 hours at room temperature or 6 hours at body 
temperature. Eead the amount of gas given off and 
its equivalent percentage of sugar on the scale. Eun 
controls : Activity of yeast, fermentable substance 
in yeast, and urine alone without yeast. 

B. Lohnstein's method. This is the most accurate. 
To % cc. of urine add .2 cc. of yeast solution (1 



85 



part yeast to 3 parts water) and layer this solution 
on the mercury in a special fermentation apparatus. 
Tilt the apparatus until the mercury in the upright 
column lies even with the zero point on the scale. 
Turn the cork so as to shut off the air and incubate 
from 5 to 6 hours and read. 

Titration metliod. 

1. Benedict's method. 

Advantages : 1. Single solution. 2. Permanent. 



3. Sharp end point, 
degree. 
Solution : 



4. Accurate to a marked 



Pure CuSO^ 
NaCOg crystaline 
Na or K citrate 
KSCN 



(accurate) 



200 gm. 

18 gm. 

200 gm. 

125 gm. 

5. 5% solution KSCN 5 cc. 

6. H2O qs. ad. 1000 cc. 

Dissolve Nos. 2, 3 and 1 in about 800 cc. of boiling 
HgO and filter. To filtrate add No. 1 dissolved in hot 
H2O. Allow to cool and add ^o. 5 and Xo. G. 

Technique : 25 cc. of the reagent are placed in a 
porcelain dish and 10 to 20 gm. of NaoCOg added 
to make the end reaction more clear. Run the 
urine diluted 1 to 10 in from a buret, rapidly at 
first, Avhich gives a white precipitate, and then 2 



or 3 drops at a time, boiling 30 seconds between 
each addition. Add distilled water if the solution 
becomes low. The end reaction is the permanent 
(lisapperance of the blue color. 

Calculation: 25 cc. of the reagent equals .05 gm. 
of glucose or .053 gm. of levulose. x cc. = .05 gm., 

.05 .05 
1 cc. = gm. 1500 cc. = gm. X 10 X 1500. 

X X 

2. Bang titration method. 

Urine is boiled in a know n excess of alkaline cop- 



Continued on Page 87 





H 

a 
0} 




Seliwanoff's 

Phenylmethylhy: 

drazine 


Phenylhydrazine 
after concentra- 
tion and ex- 
traction 


o a 

Ph 




^ 


M. P. & 
Rot. of 
Osazone 


h4 


o 

hi 


2000 
Inactive 


1560 —1600 
Inactive 


1880-1930 
D. 0.480 in 
Neuberg's 
pyridin alco- 
hol mixture 


§ 

QQ 

O 

g 

(J 
Q 


Pheylhy. 
drazine 


1 


> 


Negative 
In Urine 


> 


<u 
> 

1 


.2 

1 


o 

eg 

Q 


OS 


Q 


Essential or 
Ideopathic 
inact. 
Al. & 
Diabetic 
slight D 


o 
00 


O 




1 

Ph 


0) 

I 


1) 
> 

a 


V 

^ > 


Slow 
Positive 


^ 
^ 


«3 

Z 




> 

1 


Ph 


Slow 
Positive 


Slow 
Positive 




9S 


1) 


Ph 


> 

1 


Slow 
Positive 


Slow 
Positive 


Slow 
Positive 




D t-H 


6 




en 

1 


v 

O 
G 
Ph 


Galactose 



87 



Continued From Page 86 



11 


Phloroglucin 

Orclne After 

Hydrolysis 






Heat Urine First 

and It Does Not 

Reduce 


O tH 


S '^• 


See 
Glucose & 
Levulose 


> 


> 




.2 

*en 

S 2 


t O 


> 


> 

If 

2 


5) 


D. Rot 

Iv after 

Hydrolysis 


1 

Q 


1 

1) 


> 

1 


1) 
> 


ID 

> 

<u 
"A 


4» 
> 


> 
I) 


1 


> 

1 


== 1 


Positive 

or 
Negative 


> 


> 

1 

iz; 


> 

1 


4J 

1 -s 

i 1 


Positive 
or 

Negative 


> 

1 


o > 

11 


2 


Conjugated 

Glycuronic 

acid 


% 

o 

1 


Homogentis- 
ic acid of 
Alkapton- 
uria 


6 

O 

1 



88 

per, and the copper remaining is titrated with ft 
standard solution. 
Solution: A. 

1. Potassium bicarbonate 100 gm. 

2. Potassium carbonate 500 gm. 

3. KSCN 400 gm. 

4. CuS04 25 gm. 

5. H2O qs. ad. 2000 cc. 
Dissolve 1, 2 and 3 in 1300 cc. of hot H^O in the 

order named. Dissolve No. 4 in 200 cc. of H2O 
separately. Mix while hot. Cool at room tempera- 
ture, add No. 5. 

Solution E. 

KSCN 200 gm. 

Hydroxylamine sulphate 6.25 gm. (accurate) 

H2O qs. ad. 2000 cc. 

Technique: Urine is diluted to not over .6% of 
sugar. 10 cc. of the diluted urine are placed in 
an Erlemeyer flask and 50 cc. of solution A are 
added and the contents boiled 3 minutes by the 
watch. All the sugar present is used up, but not 
all the coi^i^er present is reduced. Titrate the cop- 
per remaining with solution B until colorless. 

Calculation: 1 cc. of solution B equals 59.4 mg. 
of olucose. 



»' 



Summary of quantitative determination methods : 
Specific gravity method should be discarded where 
other instruments are available. Specific gra\ity- 
fermentation method is not very accurate unless one 
has a delicate urinometer. Fermentation methods 
are all right if sufficient controls are run. Lohn- 
stein method good. Titration method best of all. 

Estimation of sugar icith the polariscope. 

Principles : 
Light rays vibrate in all directions. Some sub- 



89 
stances have the power of double refraction, Iceland 
spar for instance. Light passing through this is 
resolved into two sets of rays, one of which vibrates 
in all directions, the other vibrates in but one plane. 
In the polariscope the entering rays are polarized 
and the ray vibrating in all directions is deflected 
by means of a Mchol prism. Another Mchol prism 
is used near the eye-piece as an analyzer. A quartz 
plate obscures half the visual field. Some substances 
have the power of turning this polarized ray to the 
right or left. The substance whose specific rotation 
is to be determined is put in a tube of a known 
length, 1 decimeter, and the polarized ray passed 
through it. After determining the zero point of 
the instrument the unknown substance is put in 
the pathway of the polarized light and the analysing 
prism turned until both sides of the field are of 
equal illumination. The degree of rotation is read 
on the scale. 

Specific rotation. 

This is the amount of rotation of 1 gram of a 
substance per cubic centimeter of water in a tube 
1 decimeter in length. 

Formula : 
AX 100 

P=: 

Sp. rt. X LD 

A = reading in degrees. 
Sp. rt. = specific rotation. 

LD = length of tube in deci- 
meters. 
P = percentage. 
P — A when the tube is of 
the proper length, viz : 
188.6 m m for glucose. 
Technique : A mixed 24-hour specimen of urine is 



90 

ina<]e free from albumin and absolutely clear. To 
do this the following may be used : 

1. Heat and acetic acid and filter. 

2. Filter after adding kieselguhr. 

3. Normal lead acetate, not basic, filter. 

4. 25% HCl and animal charcoal, filter. 

The zero point of the instrument is determined 
by taking the ayerage of 5 readings, using a sodium 
flame. This point is indicated by both sides being 
equally illuminated. Carefully fill the tube so as to 
leaye no bubble within, place in the instrument and 
take the ayerage of 5 readings. Where a 188.6 m m 
tube is used each degree of rotation equals 1% glu- 
cose. 

Essential urinary findings in diahetes. 

There is generally a polyuria caused by the liyper- 
glycaeiiiia. Sugar in the blood, not in a colloidal 
state as nornuiUy, acts as a diuretic. The amount 
of urine excreted depends upon the amount of 
hypergiycaemia. From 5 to 8 liters are excreted 
per day. Polyuria with low specific grayity would 
indicate a possible development of both diabetes 
mollitus and insipidus. When polyuria of severe 
cases diminishes on restriction of diet it indicates 
a good prognosis. When low polyuria and high 
specific gravity occur together the prognosis is more 
favorable than great polyuria and low specific grav- 
ity. 

Variations in sugar excretion. 

By securing specimens every 2 hours it is found 
that the maximum output of sugar occurs at noon 
and late afternoon. The minimum output is in the 
early morning. If one should examine a 24-hour 
mixed specimen, the concentration of sugar may be 
so low that it may be missed; hence, keep 2-hour 
specimens separate in doubtful cases and examine. 



91 

Amount of sugar excreted. 

The average percentage of sugar in the urine in 
diabetes is from 2 to 3%. 3% at 3 liters a day 
would give 90 grams. Maximum output 1500 gm. 
6 to 8% is considered high. More is excreted on a 
hot than a cold day. In febrile conditions there is 
a tendency for glycosuria to disappear. The amount 
of sugar is increased on a carbohydrate rich diet. 
Sometimes lactose or levulose are tolerated well. 
The amount of sugar excreted usually falls during 
diabetic coma. 

Specific gravity. 

The specific gravity is usually high, varying from 
1025 to 1010. 1074 has been reached. In urines 
with 1060 readings and over, look out for frauds. 
Sugar may occur in urines with a specific gravity 
as low as 1007 to 1016. 

Color of urine. 

The color is usually a pale greenish yellow. A 
pale color with a high specific gravity is character- 
istic. 

Acidosis. 

The characteristics of the urine are : 

1. Acid bodies are present, B oxybutyric acid 

acetone and diacetic acid. 

2. The reaction is characteristically acid, rarely 

neutral or alkaline. By the Folin titration 
method there is increased alkali tolerance. 
JS^ormally an individual will excrete alka- 
line urine upon the ingestion of from 5 to 
10 grams of sodium bicarbonate; in dia- 
betes it will require from 100 to 250 grams 
a day to make the urine alkaline. 

Nitrogen elimination in dia'betes. 

Normally 15 gm. are eliminated in 24 hours. In 
diabetes 20 to 30 grams are excreted. The nitrogen 



92 
pardtioii is inicliaiiged iiiitir acidosis appears, when 
the NHg increases. Severe symptoms are indicated 
Avhen the XH3 ontpnt reaches 2 or more grams per 
day. 

Amino acid nitrogen in diahetes. 

Xormally .1 gm. per day is excreted. In diabetes 
this is increased to abont .9 gm. 

Alhiimijiuria and casts in diabetes. 

Albnmin and casts are seen in patients passed 
middle life in whom there is arterial or nephritic 
change. Kolz's sign is showers of hyaline casts 
preceding acidosis or coma. 

Acid hodies in tJie iwinc. 

These inclnde 3 substances : 
B oxybntyric acid. Diacetic acid. Acetone. 

(^H, ' CH3 CH3 

( ^H( )II — H. = CO — COo = CO 

CH. CH2 CH3 

(;00H COOH 

Although these bodies occur in diabetes, they also 
occur in other conditions. The}^ may arise from 
car})()hydrates, fats or proteins. From a carbohy- 
drate source there is no evidence, but there is a pos- 
sibility of their coming from the tyrosin group of 
protein. There is no parallelism, however, between 
their excretion and destruction of body protein as 
there is between their excretion and fat destruction. 

Tests for acetone : 

LegaFs. To about 8 cc. of urine add a few crystals 
of sodium nitroprussid and a few drops of NaOH 
or KOH, which gives a red color and which fades to 
a yellow both in normal and diabetic urine, except 
tliat the transition is sloAver in the latter. While 
still red add a few drops of glacial acetic acid, and 
if the urine changes to a purple or deep red color 
it denotes the presence of acetone. If it changes 



93 

to a green color it shows the presence of creatinin. 

Le XQble'!^\ This test is better than Legal's, for 
it eliminates aldehyde bodies and creatinin. To 
about 8 cc. of urine add a few crystals of sodium 
nitroprussid and a fcAV droj^s of NH^OH. Before 
the red color fades to a yellow add a few drops of 
glacial acetic acid as before. A deep red or purple 
color indicates the presence of acetone. 

Lieben's. Depends upon the formation of iodoform 
crystals. To about 5 cc. of urine add a small quan- 
tity of Lugal's solution or tincture of iodine and a 
few drops of XaOH. Warm slightly and examine 
the precipitate for iodoform crystals. 

Gunning's modification of Lieben\s is a more spe- 
cific test. To a small quantity of urine add about 
5 cc. of either Lugal's solution or tincture of iodine, 
and then NH^OH till a permanent precipitate forms. 
Upon standing this turns to a yellow or yellowish 
brown color, and upon microscopical examinati<-n 
hexagonal crystals of iodoform are found. It is 
preferable to set the solution aside for 24 hours be- 
fore examination. 

Frommer's. This test is the most specific, being 
sensitive in dilution 1 — 1,000,000. The reagent used 
is a 10% alcoholic solution of salicylaldehyde. To 
a small quantity of urine add a few drops of NaOH 
or KOH and 10 to 12 drops of the reagent. Keep in 
water bath at 72 degrees for 3 or 1 minutes. A 
purple or dark red color indicates a positive reaction. 

Le Noble's modification of Legal's test and Gun- 
ning's test are best clinically. 

Diacetic acid. 

Gerhardt's test. Reagent: 10% ferric chloride 
solution. 

Add reagent to urine in slight excess, whereupon 
a precipitate of phosphates forms. Either filter at 



94 

this point or continue adding the reagent without 
filtering. It is better to filter. Upon the addition 
of more reagent the previous reddish-brown color is 
changed to a Burgundy red. This test is also given 
by salicylates, conjugated glycuronates, after taking 
phenacetine, antii)yrene, acetates and trionate medi- 
cation. These can be differentiated, however, by first 
heating. Diacetic acid is broken up and color dis- 
appears ; drugs, on the other hand, continue to give 
the reaction. 

B oxybutyric acid. 

There is no satisfactory test for this. The urine 
shoAvs a greater titration determination than is in- 
dicated by the polaroscope. It is L-rotatory, specific 
rotation being — 24.12 degrees. Urine after fermen- 
tation still L-rotatory also points to B -oxybutyric 
acid. 

Autoketo)iogemc junction of carbohydrates. 

1. Administration of carbohydrates diminishes 

ketones. 

2. Lipaemia is associated with maximum excre- 

tion of acetone bodies. 

3. Administration of fatty acids is followed by 

excretion of acetone bodies in animals. 
This occurs also in people on an insufficient 
diet or who have an error in metabolism 
where carbohydrates do not spare fats. 

This condition is characterized by the following : 
A. 1. Large amounts of acetone bodies 
2. Increased NHg. 

3. No characteristic anatomical lesion 
This condition is found in diabetes, starvation and 
cachexia. 



95 

2. Excess of XH.. 

o. Large amounts of uuoxidized X and lactic 
acid 
This condition is found in plios. poisoning, cliloro- 
form poisoning, toxaemia or pregnancy and cyclic 
vomiting. 

Coma supervenes when acetone bodies are in the 
greatest concentration, in both the blood and the 
urine. Coma does not occur in their absence. 

Acidosis is further proved to be the cause of coma : 

1. There is decreased alkali in the blood. 

2. Concentration of CO^ in the blood reduced 

from 36 m m to as low as 3.2 m m tension. 

3. There is a greatly increased alkali tolerance. 

4. Administration of alkali results in improve- 

ment. 
Allen's theory of diabetes. 

1. Pancreas is the seat of the trouble. 

2. Diabetes is a specific disease. 

3. It is explained by a lack of amboceptor, which 

is necessary to produce blood colloidal 
sugar. Sugar free in the blood and not 
in a colloidal state acts as a diuretic. 
Treatment. 

1. SuiDply deficient amboceptor. 

2. Protection. Restrict carbohydrates up to a 

point of no sugar in the urine and blood 
sugar not greater than .17% and no ace- 
tone bodies in the urine. By restricting 
the carbohydrates you attack acidosis. 
There is no explanation for this except that 
by starvation you make the body learn to 
metabolize sugar properly. 

Dia'betes insipklus. 

This is a condition characterized by the excretion 
of large amounts of urine with a low specific gravity 



96 

without any demonstrable kidney lesion. The con- 
dition frequently shows a hereditary disposition. 
Symptomatic group. 

1. Polydypsia (excessive fluid intake). 

2. Central nervous system injuries. Lues r^ften 

found at autopsy. 

Ideopathic group. 

Lately some internal glandular pathology has 
been determined. Sometimes the posterior lobe of 
the hypophysis has been found diseased, especially 
in distrophia adiposa genetalia. The inability of 
the kidney to concentrate urine is the chief symp- 
tom. When salt is given to a normal individual he 
excretes it with a rise in the specific gravity of the 
urine. In this condition the concentration in the 
urine remains unchanged, but a greater quantity 
of fluid is excreted. The total solids are the same, 
but more fluids are required in the latter condition. 

Characteristics of the disease. 

1. Polyuria with 5 to 49 liters a day. 

2. Excessive thirst. 

3. Urine: 

a. Low specific gravity. 

b. Practically colorless. 
. c. Weakly acid. 

d. Hypotonic (bl6od cells rapidly disin- 

tegrate). 

e. Polyuria greater at night. 

f . Free from albumin and sugar. 
Ferments in the urine. 

Pepsin. Normal in small amounts and easily de- 
tected. It is absent in gastric carcinoma, subacidity 
and occasionally in achylia gastrica. It is increased 
in pneumonia and is of some prognostic value. 

Test for pepsin. 

Fibrin is washed and then soaked in the urine 



97 

for from 5 to 6 hours. It is then placed in a weak 
solution of HCl and incubated. If pepsin is present 
digestion will take place. 

Lipase. NormallT present, but in smaller amounts 
than pepsin. It is increased in jaundice, diabetes 
mellitus and hemorrhagic pancreatitis. 

Test for lipase (Castle and Loevenhart). 

Flash A Flash B Flash C 

Urine 5 cc. Boiled urine 5 c c. Urine 5 cc. 

Phenolphthalein x cc. N'/IO XaOH x cc. y/iO NaOH 

N710 NaOH to a .25 cc. ethylbutyrate .2." cc. ethyllnityrate 

pink color — x cc. 1 cc. toluol 1 cc. toluol 

Incubate flasks B and C for 21 hours at 37% 
degrees. At the end of this time add % cc. more 
of X/10 HCl than X/10 XaOH, extract with 25 cc. 
of alcohol and 50 cc. of ether. Titrate to end point, 
using phenolphthalein as indicator. 

1 cc N/10 XaOH equals .0088 grams butyric acid. 

Diastase. Origin not known. It may have its 
origin from polvmorphoneutrophils of the blood, the 
pancreas, or the liver. It is formed from great meas- 
ure from the pancreas, for removal of this organ 
causes a great diminution in the amount of diastase. 

Wohlgemuth's test. 

Keagent : 1% starch solution free from precipitate. 

Dilute 2 cc. of urine with 6 cc. of distilled water. 

Into each of 9 test tubes add 5 cc. of the 1% starch 
solution and then the following amounts of the 
diluted urine : Tube 1, .88 cc. ; tube 2, .72 cc. ; tube 3, 
.50 cc. ; tube I, .10 cc. ; tube, 5, .32 cc. ; tube 6, .24 cc. ; 
tube 7, .16 cc. ; tube 8, .08 cc, and tube 9, .00 cc. 
x\dd sufficient distilled water to each ttibe to make 
the volimie up to 6 cc, and a small amount of toluol 
to prevent bacterial action. Cork tubes and incubate 
at 37I/2 degrees for 21 hours. At the end of this 
time check action of ferments by chilling in ice 
Avater. Fill tubes nearly to top with cold water, 



98 

add 3 drops of X/10 iodine solution and shake. 
Determine the highest dilution which shows no blue 
color, and the amounts of starch and urine therein. 
For instance, if tube 5, with .32 cc. of diluted urine, 
should be the first tube not to show the reaction, it 
would mean that .08 cc. of undiluted urine were 
capable of completely si)litting 5 cc. of 1% starch. 
Formula : .08 : 5 : : 1.0 : x or x = 62.5 



99 
STOMACH ANALYSIS. 

The study of gastric analysis divides itself into 
four subdivisions, dependent upon the four chief 
functions of the stomach: 

1. That of a mixing chamber in which the food 
is prepared for the later intestinal digestion — hence 
a study of Secretion. 

2. That of digestion — hence a study of Ferments. 

3. That of a reservoir from which food passes fur 
ther along, requiring a study of Motility. 

4. That of a place of absorption, requiring a study 
of Absorption. 

AVe shall limit ourselves to the knowledge obtain- 
able from a study of the gastric contents and leave 
to other departments the additional important in- 
formation to be gained by direct abdominal examin- 
ation and X-ray. 

The condition of the gastric contents may be 
studied from the vomitus or by emptying the stom- 
ach by means of the stomach tube. By this means 
we may study the activity of the stomach — as to its 
powers of secretion, ferment formation, motility, 
and absorption. 

I. Secretions. 

A. Vomitus. Vomitus consists of stomach con- 
tents plus mucus and saliva. It represents no defi- 
nite phase in gastric digestion; it is, therefore, of 
much less value along certain important lines than 
the gastric contents artificially removed. Much val- 
uable information can be gained from its study, how- 
ever, especially in the following particulars : 1' Time 
of vomiting. 2. Amount. 3. Keaction. 4. Odor. 
5. Color. 6. Macroscopical contents. 7. Microscop- 
ical examination. . 



100 
Types of Tomiting. 

1. Cerebral. 

a. Organic brain changes (no nausea, projec- 

tile). 

b. Drugs. Apomorphine. 

2. Systematic. 

a. Local. Drugs, emetics, acute gastritis. 

b. Psychic — unpleasant sights or smell. 

c. Toxic. Uraemia, pregnancy, ethyl, alcohol. 

d. Keflex. Gastric crises, acute inflammation 

of gastrointestinal tract, renal colic. 

e. Obstructions. 
Points of special interest. 

1. Time. 

Morning (alcoholism, pregnancy, hypersecre- 
tion). 

After meals (ulcer, esophageal obstruction, 
pyloric obstruction). 

Definite time (neurotic). 

2. Amount (relation to food and water intake). 
Large (stasis-atony or obstruction — shows 

food remains). 
Hypersecretion has little or no food present. 

3. Reaction. The reaction is acid, with the fol- 

ing exceptions : 

1. Esor>hageal obstruction. 

2. Presence of intestinal contents (bad 

retching). 

3. Occasionally in achylia. 

4. Alkali poisoning, or therapy. 

4. Odor. 

1. Fecal (obstruction, paralytic ileus, perito- 

nitis with complete motor insufficiency). 

2. Almonds (hj^drocA^anic poisoning). 

3. Garlic (arsenated hydrogen). 

4. Sour (uraemic, acetone), etc.). 



101 

5. Color. Varies Avith presence of: 1, food; 2, 

bile; 3, blood; 4, poisous; 5, fungi. 

6. Macroscopic appearance. 

1. Bile (retching). 

2. Food (retention). 

3. Blood (dark red or coffee ground). 

4. Fecal. 

5. Cancer tissue. 

6. Mucus. 

7. Microscopical examination, (see under Fast- 

ing stomach), 

8. Chemical analysis (see under Test meals). 
B. Stomach tube. It is better taken if ice cold 

and lubricated with oil. Some cases warrant cocain- 
izing the throat. 

1. Factors regarding patient. He should be sit- 
ting upright or lying on side. A rubber apron should 
be tied around neck so as to prevent soiling clothes. 
False teeth should be removed and other foreign 
bodies. He should be instructed to breath normally. 

2. Passage of tube. Hold as a pen, avoid pressing 
on tongue, and push back to posterior wall and then 
down. A swallowing movement at this point helps. 
Kesistance is encountered on the floor of the stom- 
ach, 40 cm. or 18 in. in adults, 9 in. in child). Re- 
move tube if there is great pallor or cyanosis. 

3. Emptying stomach. Have patient cough, or 
bear down with abdominal muscles or use Politzer 
or Boas bags. 

Indications for the passage of the stomach tube. 

1. Emptying the stomach in poisoning, disten- 

tion or stasis. 

2. Lavage in stasis, fermentation, mucus, hic- 

coughs, post-operative vomiting or chronic 
ulcer with high acidity. A pint of warm 
water is usually safe for an adult with 



102 

sodium bicarbonate or HCl, as the case 
demands. Beware of habit formation. 

3. Gavage. Coma, forced feeding, local mouth 

conditions, pyloric stenosis (infancy). 

4. Medication. Castor oil, salts, emetics, silver 

nitrate, etc. 

Contraindications for the passage of the stomach 
tube. 

1. All general conditions in which excitement 

and retching are associated with harmful 
results to the patient. 

2. Local conditions in which trauma associated 

with its passage might be dangerous as 
aneurism, esophageal vacicosities, bleeding 
ulcer, corrosive poisons, etc. 
C. Fasting stomach examination. 
The patient should be instructed to eat a supper 
in which rice or some other easily recognized food 
is included, such as spinach, raisins, prunes, etc. 
After this meal nothing should be eaten until after 
the passage of the stomach tube the following morn- 
ing. 

1. Normal findings. 

a. Macroscopic. 10 — 100 cc. fluid, often bile 

tinged from retching. There may be a 
few streaks of blood from injury to the 
mucus membrane. No food remains should 
be present. 

b. Microscopic. An occasional starch granule 

and a few bacteria. No yeasts, no Oppler- 
Boas bacilli, no sarcinae, no food remains. 

c. Chemical. The gastric contents should be 

slightly acid (usually test for free HCl). 
No lactic acid should be present and is not 
tested for a^ a routine unless suspected. 
Guiac test should be negative and is not 



103 

tested for as a routine. Hoiiseiiiann's test 
should be negative. This test is used to 
determine retention and is carried out in 
the following manner : 

Allow the gastric contents to stand in a 
conical container for about 30 minutes; 
pour off the supernatent fluid, add 10 — 15 
drops of Lugal's solution or iodine to the 
sediment and water till transparent. 
Starch granules show up blue and are in- 
dicative of retention. 

2. Abnormal findings. 

a. Macroscopic. Food remains, large amount 

of fluid (hypersecretion), body tissues 
(cancer fragments, blood, pus, mucus), 
foreign bodies (rarely), parasites. 

b. Microscopic. Oppler-Boas bacilli, B. Bul- 

garicus, sarcinae, yeasts, infusoria, pro- 
tozoa (amoeba, flagellates), eggs and 
worms. Food remains (meat fibers, starch, 
fats). Crystals, fatty acid, triple phos- 
phates, calcium oxalate, bile crystals (leu- 
cin, tyrosin, cholesterin). Body cells 
r.b.c, w.b.c, cancer cells). 

D. Test meals. The advantage of giving test 
meals and then obtaining the gastric contents is 
that a study can be made of the effects of various 
meals on normal individuals and a standard can be 
obtained by which we can judge deviations in the 
abnormal conditions. Test meals should be of such 
a character as to (1) produce a normal, psychic and 
chemical flow of gastric juice; (2) be easily taken 
by even ill people; (3) be easily recovered (not ob- 
structing stomach tube). 



104 

Ewald test meal. 

40 grams of bread (without crust because of 
color) well masticated. 

400 cc. of water. (Tea as a substitute not ad- 
visable on account of interference with guiac 
test.) 

Remove in one hour. 

]^ormal findings : 

30 — 50 cc. fluid with residual bread. 
Free HCl 20—40%. 
Total acidity 40— G0%. 

Disadvantages : 

a. Little psychical stimulation. 

b. Some lactic acid introduced. 
Dock modification. 

1 shreaded wheat biscuit in place of bread. 
(More palatable.) 
Boas test meal. 

Oatmeal (1 liter of water, 1 tablespoonful oat- 
meal boiled to 500 cc.) 
This modification eliminates the introduction 

of lactic acid. 
Remove in one hour. 
!Xormal findings : 

Ver}^ little residual material, acidity? 
Riegel test meal. 
Mid-day heav}' meal : 

400 cc. soup, 

200 gm. beefsteak, 

150 gm. potato, 
1 glass of water. 

Remove in three to four hours. 
Advantages : 

a. Good psychicial stimulation of gastric 
juice. 

b. Longer period before removal, hence more 
information. 



105 



Disadvantages : 



a. Too heavy for many conditions. 

b. Blocks tube. 

4. Fisher test meal. 

Bread and tea (modified Ewald). 
% pound chopped, seasoned, lean beef. 
Remove in 3 hours. 
Advantages same as Riegel. 
Disadvantages : 

Too heavy for many cases. 

5. Salzer test meal. 
Double meal. 

Breakfast: Meat, milk, rice and egg. 
Four hours later : 

Stale bread and water. 

Remove one hour after second meal. 
Normal findings : 

No remains of first meal. 
Advantages : 

Especially adapted for study of motility. 
G. Sahli test meal. 

A fat savory soup of which 250 cc. are given 

and 50 cc. kept for comparison. 
Remove gastric contents 1 hour after taking 

in 2 portions : 

a. As much as can be obtained directly. 

b. With a known amount of water wash out 

the remaining. 
By reckoning the per cent of fat content 
(method of Mathieu and Remond- Webster, 
pg. 58) of the various specimens it becomes 
possible to determine quantitatively the 
amount of gastric contents in the stomach at 
the time of its removal; then by reckoning 
the acidity per cent it becomes possible to 
tell the actual amount of acid in the stomach 
and not merely its per cent. 



106 

E. Examination of recovered gastric contents. 

1. Amount. Ewald 30 — 50 cc. ^Vlore in stasis or 
livper .secretion. 

2. Reaction. Acid, rarely alkaline. Duodenal re- 
gurgitation and a few acliylias may produce an alka- 
line reaction. Generally su^cient organic acid is 
present to cause acidity. 

3. Odor, Same as for vomitu?. (Uraemic, rancid, 
acetone, fecal, etc.) 

4. Color. Limited also by previous emptying to 
bile and blood, fresh or coffee-ground. 

5. Macroscopic. Layer forination. 

Xormal. Fluid and food residue. 

Abnormal. Retained food (not removed by pre- 
vious emptying). Blood, fresh or old. Con- 
sider possibility of trauma from stomach 
tube, also rule out blood from nose, mouth, 
throat and lungs. Pus. L'lcerated carci- 
noma, ruptured abscesses, pyorrhea. Tissue. 
Especially in carcinoma. Mucus. Gastritis. 

(I. Microscopic, (See Fasting stomach.) 
7. Cliemical analysis. 

a. Routine. 

1. Presence or absence of HCl. 

2. Amount of HCl present. 

3. Amount of combined acid. 

4. Organic acids, especially lactic. 

5. Occult blood. 

b. When indicated. 

1. Ferments. 

2. Special tests (especially for cancer, which 

are taken up under that subject). 
For the acid determination the necessity of devis- 
ing methods for the differentiation of organic and 
inorganic acids is obvious. When we speak of a test 
as specific for HCl it really means for inorganic 
acids in general, but acids other than HCl are elimi- 



107 



Hated from consideration. Most of the tests we use 
as specific for HCl Avill, unfortunately, give suspici- 
ously positive results with organic acids if they are 
in high enough concentration. 
1. Qualitative tests for HCl. 

1. Litmus. Turns red from any acid. 

2. Congo red paper (filter paper dipped in 

acids it gives an orange to a pinkish 
Congo red, alcohol solution, and dried). 
It is supposed to differentiate organic 
from inorganic acids ; deep blue with HCl , 
bluish red with organic acids. AVith suffi- 
cient concentration organic acids will also 
give a definite blue. 

3. Topfer's (dimethyl amido azo benzol, 5% 

alcoholic solution). This is the most gen- 
erally used reagent. It gives a yellow color 
in alkaline solutions, and with HCl it gives 
a deep red to a pinkish orange, depending 
upon the concentration. With organic 
acids it gives an orange to a deep pinkish 
orange, depending upon the concentration. 

It is sensitive to .02 parts of HCl in 1000 cc. 

It gives suggestive positive reactions with 
organic acids in concentrations above 5%. 

4. Gunzberg's (2 gm. phloroglucin, 1 gm. vanil- 

lin in 30 cc. of absolute alcohol or in 100 
cc. 80%). Keep in dark bottle. Ivoact,^ 
with no organic acids nor acid salts re- 
gardless of concentration. 
Sensitive to .05 parts of HCl in 1000 cc. 
Method of performing test : 

1 drop of reagent is allowed to dry in a 
porcelain dish. (Heating is permissible 
without burning.) 
1 drop of gastric contents is placed over 
the drop of the dried reagent and also 
dried with great care. 



lo: 

HCl gives a purple red color. ( Miutz mod- 
ilication of Gunzberg. 
5. Boas. 

5 gm. resorcin, 
:j gill, caiie sugar, 
100 cc. 95% alcohol. 
More stable tban Gimzberg's, with similar 
delicacy and same color reactions. 
0. Tropeolin. 

Saturated alcoholic solution Tropeolin. 
Use as Gunzberg's. Less delicate and color 
ditference between organic and inorganic is 
too close to be of practical value. 
II. Quantitative Tests for Free HCl. 
1. 10 cc. of gastric contents well mixed and un- 
filtered. (Filtering causes some H2O loss and, 
therefore, HCl concentration.) If much mucus is 
present, filtering will be necessary regardless of 
slight error associated with it. 
Avoid including food in the 10 cc. 
Technique of perfonning test. 
To 10 cc. of gastric juice add a drop of Topfer's 
reagent. If a deep pink color results, proceed with 
quantitative determination. If a i)inkish orange 
color results, stop at once and do a Gunzberg test 
to determine the presence of any HCl. 

A. Should the resulting color be a deep pink or 
red color, add from a buret, drop by drop, with con- 
stant stirring, enough ^syi^ XaOH to change the 
color to a definite Jeinon color. 

Calculation: Xo. cc X/10 XaOH X 10 = acidity 
per cent. 

B. Should The resulting color with the Topfer's 
be a pink orange and although only one drop were 
used, a fresh 10 cc. of gastric contents will be neces- 
sary, for the presence of Topfer's reagent gives a 
false positive witli Gunzberg's reagent. If tlie qual- 



109 

itative test with Gunzberg's shows no HCl present, 
it will be unwise and impossible to carry ont the 
test. If the fresh gastric contents gives a positive 
(hmzberg test, then from a buret add, very care- 
fully, VIO XaOH to 10 cc. of the gastric contents 
and test with Gunzberg's reagent after the addition 
of each 1 — 2 drops, for there is not much free HCl 
present and the end j^oint must not be passed for 
accurate determination. 

Calculation : Same as with Topfer's. 

Note: Normal acidity is .'2 to .0%, probably as 
high as .5%, when just out of the gland, but quickly 
falls to .2 to .8% from contact with (1) mucus of 
gastric glands, (2) protein combination, (3) alka- 
line duodenal regurgitation. 

Expression of acidity: 

1. In terms of acidity per cent, which is the 

no. of cc. of N/IO XaOH necessary to neu- 
tralize 100 cc. of gastric contents. 

2. Actual amount of HCl present based upon 

the fact that 1 cc. of N/IO NaOH is equal 
to .00365 gm. of free HCl. Determine 100 
cc. .2 to .3% equals 20 to 10 acidity per 
cent. 
Definition of terms : 

Euchlorhydria, when free HCl is .2 to .3% or 
20 — 10 acidity pex* cent. 

Hypochlorhydria, when free HCl is decreased .1%. 
[Chronic gastritis ( subacute), incipient cancer, 
fe^'ers, severe anaemias, many mental diseases, c.p.c. 
chronic nephritis, etc.] 

Anachlorhydria, absence of free HCl. (Cancer, 
pernicious anaemia, neurasthenia, etc.) 
Aclijlia, absence of HCl and ferments. 
Hyperchlorhydria, free HCl from .2 to .9%. 
(Ulcers, chlorosis, reflex, migraine.) (Surmont- 
Dahon, defective XaCl output, compensation.) 



110 

E-,timation of HCl deficit. 

To 10 cc. of gastric contents add 1 drop of Topfer's 
reagent, Tvliicli should not give positive reaction. 
Confirm absence of free HCl with Gnnzberg's test. 
Into the 10 cc, with Topfer's reagent as an indica- 
tor, add, drop by drop, X/10 HCl, stirring con- 
stantly, nil til a definite positive reaction is obtained. 
For more accurate determination control end point 
with Gnnzberg's reagent. 

Calculation: Xo. cc. of X/10 HCl required X 10 
=: acidity per cent. 

III. Combined Acid. 

In order to calculate the entire HCl acidity per 
cent, one must determine, in addition to the free 
HCl, the HCl combined with foods, especially the 
proteins. The amount of combined HCl can be de- 
termined by one of two methods : 

1. Einhorn method. This method is simple, quick 
and sufficiently accurate for clinical work. Method 
of performing test: 

To 10 cc. of gastric contents add a drop of Top- 
fer's reagent. Titrate with X/10 XaOH and de- 
termine the free HCl. When the end point of the 
above determination is reached add a drop of phe- 
nolphthalein and continue to add X/10 XaOH until 
a definite pink color is obtained lasting at least 30 
seconds. 

Calculation: Xo. cc. XVIO XaOH required to bring 
about reaction after the free HCl has been neutral- 
ized X 10 =: acidity per cent for combined acid. 

In cases where no free HCl exists, i. e., negative 
Topfer's and Gnnzberg's reaction, the HCl deficit 
and combined HCl should be determined, which will 
require two 10 cc. portions. Determine the HCl 
deficit as above. The combined HCl is determined 
by adding the i)henolphthalein at once and titrating 
with the X/10 XaQH, The fallacies of this method 



Ill 

are obvious, for such a determiuation of conibiued 
acids includes: 1, combined HCl ; 2, acid salts; 3, 
organic acids. When the free HCl is high and there 
is no evidence of stasis, the bulk of combined acid 
determined will be represented by combined HCl, 
but where the free HCl is low or absent, especially 
when associated with stasis, acid salts and organic 
acids will often comprise the greater part of this 
acid calculation. 

2. Topfer's method. This method is of value in 
differentiating between the constituents above enu- 
merated. Procedure : 

A. Determine total acidity, including free, com- 
bined, and salts, using phenolphthalein as indicator. 
(10 cc. gastric contents plus 1 drop of indicator plus 
^NyiO XaOH till end point). Calculate acidity per 
cent. 

B. Determine free acid, both HCl and organic, 
and salts as follows : 

To 10 cc. of gastric contents add 2 — 3 drops of a 
1% aqueous solution of alizarin monosulphonate of 
sodium, which turns yelloAv with acid and violet 
with alkali. This indicator reacts with free acids, 
organic and HCl, and salts, but does not react with 
organically bound HCl. 

Titrate with N/10 XaOH till a pure violet color 
not growing darker with the addition of more alkaU. 
Cal-culate acidity per cent. 

C. Determine free HCl with Topfer's or Gunz- 
berg's reagent. Calculate acidity per cent. 

Explanatory example: 

A = 80 acidity % (includes all acids, free, salts, 
and combined). 

B = 22 acidity % (includes all acids and salts not 
organically bound). 

C = 20 acidity % (includes only free HCl). 

A — B = 58 acidity % = combined HCl (also com- 
bined organic acids if HCl is insufficient for lactic 



112 

acid being weaker will not combine as long as HCl 
is present to do so). 

B — C = 2 acidity % ^ organic acids and salts. 

(A— B) plus C = total HCl, or 78 acidity %. 

In cases where there is a free HCl deficit and 
organic acids are present, the combined acids may 
be part HCl and part organic, or all organic. AVhere 
delicate discrimination is needed and it is necessary 
to know if any HCl is excreted by the gastric 
glands, the folloAving method should be adopted: 

3. Incineration with BaCOg. 

If any HCl is present it will combine with BaCOo 
and form the soluble BaCls- The addition of HgSO^ 
will precipitate insoluble BaSO^. The appearance 
of a precipitate after this procedure signifies the 
presence of HCl. Filtration, incineration, weigh- 
ing and calculation will give amount of HCl. 
IV. Organic Acids. 

Practically all foods contain some fatty acids. 
Where rancid butter, vinegar, sour milk, etc., are 
included in the diet, the amount may be consider- 
able. Carbohydrates, contained in milk, bread, meat, 
etc., always contain some lactic acid, and the find- 
ing of an excess amount in the gastric contents after 
the ingestion of such foods points to a fermentative 
process at wqx% in the stomach, due possibly to a 
combination of decreased HCl and decreased motil- 
ity. Boas thinks that with a normal diet there 
should be no appreciable formation of organic acids 
in the stomach during normal digestion. Bacterial 
decomposition, in the absence of HCl, plan's an im- 
portant source of their production. The presence 
of a fat-splitting ferment would also produce them. 

In fermentation processes lactic acid, but^^ric acid 
and acetic acid are generalh' found. Lactic acid 
is used as an index of organic acid production, be- 
cause (1) it is produced in greater amounts than 



113 
the others and is thus more easily detected; (2) 
qualitative tests for it are quick and simple. 

Quantitative tests for organic acids are not used 
clinically. Xo clinical information is obtained by 
quantitative data because there exists no correlation 
between the amount of organic acid present and 
the severity of the lesion. 

A. Qualitative consideration of lactic acid. 

With the Ewald meal in normal digestion, as a 
rule, no lactic acid is found in the gastric contents ; 
but there is a slight abnormality, even within nor- 
mal limits, in which it may be found. In such bor- 
derline cases the use of the Boas meal is advisable. 

Normally the small amount of lactic acid in the 
EAvald meal is either (1) absorbed or (2) cannot 
be detected on account of the presence of the normal 
amount of HCl, which interferes with its tests. 

Pathologically, lactic acid appears in conditions 
of stagnation and low HCl output. Such conditions 
are, found in (1) carcinoma, with obstructive fea- 
tures ; (2 ) hypochlorhydria or achlorhydria, . with 
sluggish motility ; (3 ) benign stenosis, with low HCl 

output. .^ - - :. . . . ; 

Tests for lactic acid : ■ " .' .....,• .■ ■•• ■ 

1^ Uffelman's. -■ - :.: ;. _ 

Reagent: 1% phenol, 20 cc; dil. ferric chloride,.! 
drop; dist. water q.s. to mal^e a delicate . amethyst' 
color. . . 

Procedure : Divide amount of reagent between two 
test tubes, and into one add 5 — 8 drops of clear gas- 
tric juice (filtered, if necessary), and into the other 
add 5 — 8 drops of distilled water for a control. 

A positive test is indicated by the formation of a 
canary yellow color in the tube containing the gas- 
tric juice. If the reagent is not sufficiently diluted 
and is of too dark a color, a small amount of lactic 
acid will not give the characteristic lemon color, but 



114 

Avill simply decrease the intensity of the purple color. 

Sources of error: 1, yellow gastric juice; 2, acid 
sodium phosphate: 3, cane sugar; 4, glucose; 5, 
alcohol: 6, other organic acids. 

Modification : If doubt exists, make an ether ex- 
tract of the gastric juice, evaporate, take up the 
residue in distilled water and apply the test. 

2. Kelling modification of UJielmann's test. 
Reagent: Distilled water, 20 cc. : 10% ferric chlo- 
ride, 1 or 2 drops. 

Procedure: Divide between two test tubes. Into 
one put a few drops of clear gastric, juice, and into 
the other a fcAv drops of distilled water for a control. 
A j)ositive test, as before, is the formation of a 
canary yellow color. 

Sources of error : Same as for Uffelmann's, except 
that acetic acid will not give yellow color. 

3. Strauss test. 

This is the best clinical test, for it detects lactic 
acid when in pathological amounts. 

Procedure : Into a Strauss funnel put 5 cc. of gas- 
tric juice and a drop of HCl to free any organically- 
bound lactic acid. Upon this pour 20 cc. of alcohol- 
free ether. Invert several times, avoiding the forma- 
tion of an emulsion. Allow the gastric juice to es- 
cape through the stop-cock below and replace it with 
an equal quantity of distilled water. Shake several 
times in order that the lactic acid extracted with the 
ether can be taken up by the water and add a few 
drops of a 10% solution of ferric chloride. 

An intense green color will appear if more than 
.1% lactic acid is present, paler shades of green if 
less is present. 

B. Qualitative consideration of butyric acid. 

Physiologically, none is present in the stomach 
during digestion unless (1) hea^^^ carbohydrate 
meal has been taken, (2) it is taken directly in the 



115 

form of rancid butter, etc., (3) it finds it way into 
the gastric juice from the mouth. Fugge has shown 
that it may be formed from lactic acid. 
Method of detection : 

1. Odor specific. 

2. Shake material with ether, evaporate ether ex- 
tract, take up with water and a small amount of 
CaCU, and upon Avarming butyric acid w^ill settle 
out, recognized by (1) droplets, (2) odor of rancid 
butter. 

C. Qualitative consideration of acetic acid. 
Acetic acid is frequently found in large amounts 

when taken in the form of vinegar. Pathologically, 
it is found in conditions of stasis with yeasts and 
fungi. The stomach in this condition is usually 
dilated and atonic. Yeast action on carbohydrates 
yields alcohol, which, in turn, when acted upon by 
yeasts and bacteria, yields acetic acid. 

Method of detection : Shake the material with 
ether and extract with water. Neutralize with 
NaCOo, carefully. Acid prevents the necessary re- 
action and alkali causes formation of ferric hydrox- 
ide when ferric chloride is added. Add a few drops 
of ferric chloride and look for appearance of deep 
ved color. Upon boiling a reddish precipitate of 
basic ferric acetate will also form when acetic 'acid 
is present. 

D. Detection of blood. 

The guiac and benzidine tests are carried out in 
the same manner as for similar tests in the urine. 

II. Consideration op Ferments. 

A. Pepsin is the chief ferment and is secreted by 
the peptic glands. 

B. Lipase, which is slight in amount and of ques- 
tionable origin.. 

Possible origin: 



116 

1. Regurgitated duodenal contents, pancreatic 

origin. 

2. Derived from secretion of Brunner's glands 

in intestine. 

3. Dual origin from both. 

C. Diastase, a small amount of Avliich is of gas- 
tric origin, but the greater amount of which is due 
to swallowed saliva. 

A. Pepsin. This ferment is secreted as propepsin, 
is activated by HCl, and destroyed by alkali. Other 
acids will activate it, but in higher concentration, 
viz: HCl, .2— .4%, lactic 1—1 plus ?c: The action 
of pepsin is continuous, and a great amount of work 
is accomplished by a small amount of pepsin, pro- 
vided that the products of its digestion are removed. 
Stasis hinders its action. 

Decrease in amount of pepsin. Due to disease of 
peptic glands. Pepsin is generally present when the 
HCl is high, low or even absent. Pepsin may be 
absent in the following conditions : 1 . Carcinoma, 
especially the liniis plastica type. 2.~ Atrophic gas- 
tritis. 3. Occasionally in pernicious anaemia. The 
output of pepsin lias no relation to the amount of 
HCl present. . ' . . ' - ■' 

Qualitative tests jor pepsin: --■"'.'.:■. 

These are- based upon the digestion of protMii-in- 
the form Of il. Fibrrn, which is obtained by whip- 
ping ox blood and is then washed, kept in alcohol 
for two or three days, then carmine for two or three 
days, and finally preserved in glycerin till used. 
2. Albumin, which is made by cutting the whites 
of hard-boiled eggs into small squares and preserved 
in glycerin. 

Procedure : 1 . Into 25 cc. of gastric juice with 
free HCl place either a number of pieces of fibrin 
or albumin j^repared as above. Incubate for 15 min- 
utes to an hour. The fibrin swells up in 15 to 30 



117 

minutes and liberates the carmine. It is all gone 
normally in 1 to IV2 hours. The albumin swells 
up in 30 to 60 minutes and is well gone in three 
hours. 

Quantitative tests for pepsin. 

1. Hammerschlag's. 

1% solution of egg albumin in 0.4% 
HCl {egg albumin 1 part, 0.4% HCl 
13 parts j 10 cc. 

Gastric juice 5 cc. 

Incubate at 37 deg. for one hour and run a con- 
trol tube with 5 cc. of distilled water instead of 
gastric juice. At the end of an hour run an Esbach 
determination on both the tubes, also on the original 
1% solution. Xormallv 90% of the albumin is 
digested in the hour. 

Sources of error: Albuminoses are thrown down 
with albumin. 

2. Mett's method. (The one of choice.) 
Preparation of tubes : Take several whites of eggs, 

cut them, filter through gauze and use the liquid 
portion to fill capillary tubes 10 to 30 cm. long by 
1 to 2 mm. bore. Fill tubes by suction, seal with 
bread crumbs, drop into boiling water (95 to 100 
(leg.) for 5 minutes, and then seal ends with paraffin 
to prevent drying. AVhen read}" to use cut tubes 
into 2 cm. lengths. 

Sources of error to be avoided in preparation of 
gastric juice: 

1. If too concentrated, especially after meals, 
there may be present substances which inhabit di- 
gestion, i. e., XaCl and carbohj'drates in solution. 

2. Schultz's law holds with digestion up to 3.6 
mm. The length of the cylinder of albumin digested 
by any gastric juice is proportional to the duration 
of digestion and is independent of the diameter of 
the capillary tube, provided that the length of the 



ii3 

digested column does not exceed 7 mm. For this 
reason the gastric juice is diluted. 

8. Kesult of peptic digestion hinders further di- 
gestion. 

4. Pepsin is activated by HCl and its presence is 
essential. 

Procedure: Into a small dish place 

Filtered gastric juice 1 cc. 
.18% HCl 16 cc. 

2 cm. Mett's tubes 2 

Incubate 24 hours. Kead four ends, take aver- 
age and square. 

Note: It is often desirable to set up two addi- 
tional dilutions of gastric juice, using 32 cc. and 
64 cc. of .18% HCl to 1 cc. of gastric juice. 

Unit of digestion equals the amount of pepsin 
necessary to digest 1 mm. length of albumin in 24 
hours in the presence of .18% HCl. 

Calculation. This is based upon Schultz's law, 
which may be stated as follows : Relative amounts 
of pepsin, in constant acid solutions and time of 
action, are proportional to the square of the length 
of the column of digested albumin, or the square 
of the length of the digested cylinder of albumin 
is proportional to the pepsin concentration, pro- 
vided the length of the digested column is less than 
3.6 mm. 

Example : Average length 3 mm. 

3- X 16 (dilution) = 144 units. 

Significance: to 70 units — low. 

70 to 150 units — average. 
150 to 250 units— high. 

B. Rennin (chymosin). 

Pepsin and rennin run parallel in most cases, but 
marked variations may occur. One or the other 
may be suppressed or follow different curves of 
secretion. Some have tried to show that pepsin 



5 cc. 
10 cc. 



Coagulation shows the 



119 
and rennin are identical, but this is probably not 
true, for there are some differences between these 
two ferments, viz: pepsin acts onh^ in acid media, 
while rennin acts in acid, neutral, or slightly alka- 
line media. Its action is to make insoluble casein 
from caseinogen. 

Qualitative test for rennin: 
Neutral gastric juice 
Fresh milk 5 to 

Incubate for 15 minutes 
presence of rennin. 

Quantitative test (Boas). 

In a rack place 6 test tubes. In the first tube 
place 1 cc. of gastric juice and 9 cc. of distilled 
vv^ater, which gives a dilution of 1 to 10. Into the 
remaining tubes place 5 cc. of distilled water. With 
a 5 cc. pipette mix the contents of the first tube 
by drawing the solution up and down three or four 
times, then transfer 5 cc. of it to the second tube, 
mix as before, transfer 5 cc. from the second to the 
third tube and so on till the last tube, when 5 cc. 
are discarded after mixing. The dilutions are as 
follows : 

1. 1—10. 2. 1—20. 3. 1—10. 4. 1—80. • 
5. 1—160. 6. 1—320. 

After these dilutions have been made add to each 
tube 5 cc. of fresh or, preferably, boiled milk, and 
21/2 cc. of 1% CaC12. '^ ' 

Place in a thermostat for 30 minutes and read. 
In abnormal conditions the coagulation is low, if 
only in the first tube, interference due probably to 
acid salts. Normally, there should be coagulation 
up to 1—160. 

C. Lipase. 

This ferment does 
action is very slight. 



occasionally occur, but its 
Gastric digestion is not con- 



120 

cerned with the splitting of fats. In testing for 
this ferment be snre to nse a fat-free meal. 
Qualitative test for lipase : 

1. Wash stomach out thoroughly. 

2. Give fat-free test meal. Kemove. 

8. Incubate, adding some neutral butter. 
Positive results show presence of fatty acids. 
Examination of the duodenal contents for fer- 
ments. 

Method of obtaining duodenal contents : 
Give pt. 200 c. of olive oil by mouth. 
Half hour later pass stomach tube and obtain 
regurgitated duodenal contents. 
Set up for examination of duodenal contents for 
ferments. 





50 


^ 




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O 


9 


W 


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9p 


to 


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solution 
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. 2 cc 





2 cc 


2 cc 


2 cc 


II 








. 1 cc 


1 cc 


2 cc 


2 cc 


2 cc 


III 








. 0.7 cc 


1.3 cc 


2 cc 


2 cc 


2 cc 


IV 








, 0.4 cc 


1.6 cc 


2 cc 


2 cc 


2 cc 


V 








. 0.2 cc 


1.8 cc 


2 cc 


2 cc 


2 cc 


VI 


. , 






. 0.1 cc 


1.9 cc 


2 cc 


2 cc 


2 cc 


VII 








. 0.0 cc 
Control 


2.0 cc 


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2 cc 


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Incubate tubes at 38 deg. C for 30 min. in water 
bath, cool rapidly and read at once. 

Titrate tubes A with a saturated solution of 
NaCl, which gives white ppt. Add Lugal's solution 
to tubes B and obtain blue color if starch is pres- 
ent. Titrate tube C with N/10 XaOH, using phenol- 
phthalein as indicator. 

Method of preparing casein solution: 
X/10 XaCl 5 cc. 
Casein 0.1 gm. 

Dist. water 45 cc. 



121 

Boil, with constant watching and stirring, for 
from 3 to 5 minutes. Allow to cool, make neutral 
with HCl or N/10 NaOH ( phenolphthalein as in- 
dicator) and bring volume up to 100 cc. with dist. 
water. 

Method of preparing starch solution: 
Starch 1 gm. 

Dist. water 100 cc. 

Boil from 3 to 5 minutes, allow to cool, and make 
up volume to 100 cc. 

Method of preparing Monobutyrin solution: 
Monobut^^rin 1 cc. 
Dist. water 99 cc. 

Normally, tube No. VI. shows digestion of casein 
and starch. 

The lipase test is practically never done because 
of numerous sources of error and uncertain end 
point. 

In diastase test the last positive tube is the tube 
just before the one which shows blue, probably 
brownish, due to presence of erythrodextrin. 

Gastric digestion. 

A. Protein. Pepsin and HCl change albumin into 
acid albumin, then into albumoses (four in num- 
ber), then into peptones. Gastric digestion is not 
carried beyond the peptones or the slightly lower 
polypeptid stage. When lower products of digestion 
are found their presence is due to the action of 
other ferments, either intestinal or those excreted 
by malignant growths. 

B. Carbohydrates. Some inversion of sugar oc- 
curs in stomach, due to t]ie acid there present. By 
the action of the salivary ferment starch is changed 
into soluble starch, erythrodextrin, achrodextrin 
and, finall}', into maltose. Ptyalin does not act in 
the presence of free HCl, but its action is so rapid 
that from 50 to 75% of starch is converted into the 



122 

soluble forn:. If the HCl is kept low, starch diges- 
tion will continue much farther than when it is 
present in higher concentrations. 

C. Fat. Practically none is digested normally as 
lipase is present only in a trace. 

Motility. 

Disturbance in tliis function of the stomach is of 
more imj^ortance than its secretory disorders. Food 
can pass into the intestine and be digested there 
irrespectiye of gastric secretion. If motility is im- 
paired, howeyer, food stays and stagnates in the 
stomach, causing more or less disturbance. 

Motor disturbances : 

1. ^'omiting, already cousidered, important be- 

cause of loss of food. 

2. Hypermotility, in which condition food is 

rushed through, and often associated with 
hyperacidity. Consider spasm also in these 
conditions.) 
.']. Hypomotility, which is important and seri- 
ous. 
Results of motor disturbances: 1. Disorders of 
secretiou. :?. Disorders of digestion. 3. Disorders 
of absorption. 
Causes of stasis : 

1. Cancer with obstruction, associated general]}' 

with hypochlorhydria, achlorhydria or 
achylia. 

2. Fleer with obstruction, associated generally 

with hyperchlorhy dria . 
?. Spasm, generally associated Ayith hyperchlo- 
rhydria. 

4. Atony, witli or without hypersecretion. 

5. I'tosis, which interferes Ayith mechanical 

passage of food. 
Study of Motility. 

1. Xot by acid content. 



123 

2. Not bj the size of the stomach, for a large 
stomach may have normal motility. 
Terms : Ectasia (or ectasis) signifies dilation with 
motor insufiiciency. Atonic gastric ectasia signifies 
weakness of muscles of stomach. Hypertonic gas- 
tric ectasia signifies pyloric stenosis. 

Food should be out of the stomach in from 7 to 8 
hours, no matter how heavy or large the meal. 
Tests which give information of gastric motility. 

a. Leube. A Riegel meal is washed out in 6 hours 
with 1 liter of water. Normal equals slight trace of 
food. 

b. Boas. A simple evening meal of meat, bread 
and butter is washed out the next day. If any food 
remains there is considerable motor insufficiency. 

c. Ewald-Siever's method : 1 gram of salol is given 
after a meal and the urine is collected every 15 min- 
utes for 2 hours. Test with ferric chloride for 
phenol, which gives violet color. Salol is broken 
down in the alkaline media of the small intestine 
into phenol and salicylates and is excreted in the 
urine. 

Difficulties of test: 

1. The gastric juice acts slightly upon salol in 

about 15 minutes, breaking it up. 

2. Small amounts of salicylic acid and phenol 

may be absorbed from the stomach. 

Normally, phenol appears in the urine in from 
45 to 75 minutes and is all excreted in 24 to 27 hours. 

Abnormally, if not detected before 75 minutes in- 
dicates motor insufficiency; if not detected before 
24 hours indicates stenosis. If detected in 15 min- 
utes an error is indicated. 

d. Winternitz. The method is the same as the 
preceding, except that iodipin is used in place of 
salol. Iodipin is not touched by the gastric juice, 
but requires pancreatic secretions and bile to free 



124 

iodiii. Tlie snliva is tested for iodin with si arch 
paste. Xormallv, it appears in from 15 to 45 min- 
utes. 

e. Sahli test meal (fat soup), (see text books for 
detail.) The method is incorrect if lipase is pres- 
ent in the stomach. 

f. An evening meal of substances easily recog- 
nized, such as raisins, rice, spinach, etc. Recover}^ 
of any of the meal (macroscopically or microscopi- 
cally) the next morning shows impaired motility of 
a degree depending upon the findings. 

g. Direct fluoroscopic examination with barium, 
wliich is the best method when available. 

Consideration oi absorption. Not of much im- 
poitance clinically. 

Penzoldt-Faber test : 

Two to o grains of KI are given in a capsule after 
a meal, which is rapidly absorbed by the mucus 
membrane and appears in the saliva, normally, in 
oO vo 40 minutes. Test the saliva every few minutes 
^^'itll a fcAV drops of HX03 and a small amount of 
starch paste, when a positive reaction is indicated 
by a blue color. 

Indirect examinations. 

Where it is not possible to remove contents of 
stonuich, indirect methods may be used. They are 
not very accurate, but may give much help at times. 

a. (iunzberg's method: 0.2 gm. of KI are placed 
in the thinnest possible strongly vulcanized rubber 
tubing about 2.5 cm. long, which is then tied wath 
three threads of fibrin hardened in alcohol. Test 
by placing in water for 1 hour to be sure of no 
leak. The patient is allowed to swallow the bag 
three-quarters of an hour after an Ewald meal. Test 
saliva as in Penzoldt test. The HCl and pepsin 
digest the fibrin threads and free the KI which is 



125 

absorbed. It should appear in the saliva in three- 
quarters of an hour. 

b. Sahli's Desmoid bag. A bag of ordinary rub- 
ber-dam, containing a 0.05 gm. pill of methylene blue 
and 0.1 gm. of iodoform, tied with dried but chemi- 
cally-untreated catgut, which is digested by the gas- 
tric ferments, but not the pancreatic. The bag is 
swallowed after the noon meal. The methylene blue 
appears in the urine, normally, in 6 hours, coloring 
it green ; iodin in the saliva in 2 hours. 

Special test for carcinoma. 

Wolff Junghan's test. This is a soluble albumin 
test for carcinoma, very delicate, and applicable 
only to stomach contents. There should be no free 
HCl present and no occult blood for the successful 
application of the test, and it should be read within 
half hour after it has been set up. Positive results 
occurring after that time should be ignored. 

Reagent : Phosphotungstic acid 0.3 gm. 

HCl (concentrated) 1.0 cc. 

96% alcohol 20.0 cc. 

Distilled water qs. ad. 200.0 cc. 

Procedure : Six carefully cleaned test tubes 
(cleaned with soap and water, alcohol and ether) 
are put in a rack and to them are added the fol- 
lowing : 

Tubes I II III IV V VI 

Filtered gastric 

contents. Ice O.o cc 0.2 cc 0.1 cc 0.05 cc 0.025 cc 

Dist. water 9 cc 9.5 cc 9.8 cc 9.9 cc 9.95 cc 9.975 cc 

Dilution equals ..1-10 1-20 1-50 1-100 1-200 1-400 

After these dilutions have been made apply a clean 
rubber stopper to each tube and invert several times 
to mix. Do not use fingers as stoppers on account of 
errors in test. 

1 cc. of the I'eagent is now carefully layered on 



126 

each of the tubes, which layering must be perfect. 

The presence of a white ring in the first three 
tubes is normal. A ring in the fourth is non-com- 
mittal. A ring in the fifth or sixth speaks for car- 
cinoma and is considered a positive test. 

Several points of clinical value : 

1. High free HCl with low combined suggests 
liyperchlorhydria with hypermotility. 

2. High (or normal) free HCl with high combined 
suggests hyperchlorhydria with stasis, probably 
spasm or stenosis. 

3. Low free HCl with moderate combined sug- 
gests hypomotility with perhaps normal acid output. 

1. HCl deficit with high combined suggests stasis 
with organic acid production. 

5. HCl and mucus vary inversely as to their 
amounts. Mucus is never found with a high HCl. 
In gastritis, where mucus is characteristically pres- 
ent, HCl is low or absent. 

6. Organic acids do not form if HCl is present in 
normal or increased amounts. 



127 

SPUTUM. 

Deriiiition : Sputum mcliides all the secretions 
which come from the respiratory passages. 

Collection of sputum. Avoid coutaminatioii from 
the mouth especially when making cultures. In chil- 
dren this can he done by stretching a piece of gauze 
over the finger and tickling the tliroat. The child 
AviJl cough and raise sputum, Avhicli will adhere to 
the gauze. When a quantitative examination is to 
be made, collect sputum in conical glass containers 
and look for stratification. Sometimes the gastric 
contents are examined in patients who swallow 
their sputum. 
Color of sputum: 
Gray — mucus. 
YelloAA' — pus ( purulent ) . 
Yellowish-gray — pus and mucus (muco-puru- 

lent) . 
Red — blood usually. When the lung is the 
source, it is frothy; when from the mouth, it 
its not frothy; when from the stomach, it is 
dark red or coffee-ground in appearance, and 
is never frothy. 
Occjurrence of hlood in the sputum {hemoptysis), 

1. Pneumonia. 

2. Infraction of lung. 
?). Weeping aneurism. 

4. Tuberculosis. 

5. Tumor metastasis to lung. 
G. Blastomycosis. 

7. Echinococcus cysts. 

8. Paragonimus westermani (lung fluke). 
Green — resolving pneumonia, pj^ocyaneus infec- 
tion, rupture of subdiaphragmatic abscess. 

Black — coal and iron workers. 

White — starch granules in sputum of bakers. 

Various colors — dve workers. 



12B 

An} Oil lit of spuiuni. This varies within a wide 
range. Large amounts are met with in : 

J. Branchial affections with much secretion. 
1\ Bronchiectatic and tubercular cavities. 

3. Pulmonary edema. 

4. Perforating empyemas. 

Odor of sputum. Normally the sputum should 
have no odor. 

Sweetish odor — pulmonary abscess, occasionally 
in tbc. and oral sepsis. 

Foul — putrid bronchitis, gangrene, bronchiec- 
tasis. 

Cheese-like — perforating empyema. 

Putrefactive — stagnation in lungs or receiving 
cup. 
Macroscopic appearance. 

Layer formation. Top, frothy; bottom, granu- 
lar ; serous fluid between ; used to be consid- 
ered diagnostic of bronchiestasis, but it may 
occur whenever there are large amounts of 
sputum. 

Curshmann's spirals. These consist of a central 
core around which are wound strands of 
threads. The core is highly retractile and 
may be fibrin. Microscopical examination is 
necessary in order to make out the structure 
Charcot-Leyden crystals and eosinophiles are 
usually found with them. 

Dittrich's plugs. These are cheese-like masses 
usually about the size of a mustard seed, yel- 
lowish-Avhite to gray in color, sometimes form- 
ing casts of the bronchi or bronchioles from 
which they come. They are also of frequent 
occurrence in the crypts of tonsils of other- 
wise normal individuals. Upon crushing them 
they give a disagreeable odor. Microscopi- 
cally, they show large numbei^s of bacteria, 



129 
fatty acid crystals, fat globules and cellular 
detritus. 

Cheesy masses (rice bodies). These are small, 
yellowish masses varyinci- in size from that of 
a pin-]wint to a pea. They may be pigmented 
by decomposition products of hemoglobin. 
Upon crushing tliey do not give a disagreeable 
odor. They occur most frequently in tuber- 
culosis, also in abscess and gangrene. 

Fibrinous casts. In as much as not all the 
material making up these casts is fibrin, they 
are more properly called "bronchial casts.'' 
Many are branching and the size of the bron- 
chus from whicli they came. When composed 
of fibrin, they stain beautifully with Weigert's 
fibrin stain. With acetic acid they are not 
precipitated, and are friable in consistency. 
They occur in pneumonia and fibrinous bron- 
chitis. 

Bronchioliths. Tliese are calcified collections 
of debris and secretions. 

Pneumoliths. The majority of these are tuber- 
cttlous in origin, formed by the calcification 
of caseotis areas. They have a chalky or cal- 
carious consistency. 

Elastic tissue. This appears as grayish, opaqtie 
flakes, which are most readily recognized by 
ptitting the sptitum between two glass plates 
and looking toward the light. The other struc- 
tures can be dissolved away by boiling the 
sputum in 10% XaOH, eqtial parts of each, 
after which the sputum is diltited and the 
sediment examined. The fibrils of elastic tis- 
sue are not as wavy as those of fibrous tissue 
and are not dissolved by XaOH. 
Origin of elastic tissue: 

1. Walls of arteries. Appear in sheets. 



130 

-. Bronchi. Have branches. 
3. Alveoli. Appear in squares. 

When elastic tissue is found it means lung 
destruction. 
Echinococcus membranes. These ma}'^ be ex- 
pectorated in rather large masses, which are 
tough, thick and porcelaindike in color. 
3Jicroscopically, they show laminated struc- 
ture. 
Microscopical exu in i nation. 

White blood cells. The ordinary ])olymorpho 
nuclear neutrophil is of little significance and 
is almost invariably found. The eosinophiles 
are found in asthma associated Avith Charcot- 
Leyden crystals. 
Red blood cells. These, also, are of little im- 
portance. 
Epithelial cells. 

J. Pavement ejnthelium coming from mouthy 

pharynx and upper larynx. 
2. Cylindrical e]nthelium coming from nose 
and bronchi may be ciliated. 
'.\. Alveolar epithelium coming from alveoli 
often contain coal pigment ' (phthisis 
melanoticaj and are found in normal 
sputum, especially in the morning. They 
are increased in any irritation of the 
respiratory tract. In chronic passive 
congestion of the lungs they often con- 
tain hemotoidin or hemosiderin granules, 
and are then known as ''heart-failure 
cells." 
iUifSitals. 

Patty-acid. These needle-shaped crystals occur 
singly or in group-. Heat changes them into 
fat droplets. They are soluble in ether and 
alkali. They occur in gangrene, putrid bron- 
chitis, and chronic tuberculosis. 



131 

Cliolcsteriii. Tliese crystals resemble steps 
superimposed upon one another. They occur 
frequently in association with fatty-acid crys- 
tals in empyema, chronic lung abcesses and 
chronic tuberculosis. 

Hematoidin. These crystals are rhomboid or 
needle-shaped, and ruby-red in color. They 
occur rarely in lung abscesses, empyenui, per- 
forating liver abscesses and old hemorrhages. 

Tyrosin and leucin. These crystals are of rare 
occurrence and are formed only by the decom- 
position of protein material. They occur in 
empyema, lung abscess or perforating liver 
abscess. 

Triple phosphates. These occur in the same 
conditions as leucin and tyrosin. 

Calcium oxalate. These occur in conditions 
associated A^■itll decomposition. 

Charcot-Leyden. These are found in association 
Avith eosinophiles and are probably derived 
from them. They occur most frequently in 
asthma, and less frequently in fibrinous bron- 
chitis and hav fever. 



1 niriial pcn'osites. 

1. Amoeba buccalis (A. gingivalis and A. den- 

talis probably the same). 

2. Amoeba histolytica. This parasite ma}' occur 

in rupture of amoebic abscess through dia- 
phragm. See section on parasites. 
.*). Echinococcus granulosus and cysticus. The 
booklets, scolices, or portions of the cyst 
wall will diagnosticate the condition. These 
should be looked for in unexi^lained hemor- 



rhages from the lungs. 



132 

4. Pargonimus westermani (lung fluke). Look 
for the eggs of this parasite, Avhich are 
operculated on blunt end. They measure 
.1 mm. X .05 mm. This parasite is a com- 
mon cause of heilioptysis in Japan. 
Fungi. 

1. Streptothrix actinomyces. The sputum with 

this infection is glairy and mucilaginous 
or purulent and contains yellowish gran- 
ules about the size of a pin head, the so- 
called ''sulphur granules." If one of these 
granules is placed upon a slide and crushed 
with a coyer-slip and examined, threads 
are found centrally and club-shaped proc- 
esses are seen peripherally. The}^ can be 
stained with Lugal's solution. 

2. Aspergillus. Look for doubly-contoured 

threads with brownish pigmented spores. 
They are best seen after the sputum has 
been treated with 10% KOH. They occur 
occasionally in bronchiectasis and tuber- 
culosis. 

3. Blastomyces. Treat the sputum with dilute 

KOH and look for yeast-like, doubly-con- 
toured, retractile bodies. They occur occa- 
sionally in systematic blastomycosis. 
Bacteria. 

I. Tubercle bacillus. Pick out grayish opaque 
flakes and stain with Ziehl-jN^eelsen stain: 

5% carbolic acid water 90 parts 

Concentrated alcoholic fuchsin 10 parts 
Stain for three minutes, during Avhich time gently 
heat oyer a bunsen flame and replace the stain as it 
eyaporates. AYash the excess of stain off with water 
and decolorize witli a 2% solution of HCl in 80% 
alcohol. When no more stain comes off', counter- 
stain Ayith 1% methylene blue. The tubercle bacilli. 



133 

I'etain tlie red fuslisiii stain wliile tlie other elements; 
are decolorized and take the bine stain. It is of 
importance that not all acid-fast organisms are 
alcohol acid-fast as is the tnbercle bacillus. 

Allien a more careful search, is desired, the anti- 
formin method should be used. A good modification 
is that of Loeffler's : 10 to 20 cc. of sputum are 
mixed with an equal quantity of 

Sodium hypochlorite 10 grams 
Sodium hydroxide 10 grams 

Water 100 cc. 

Boil for not longer than 15 minutes and centri- 
fugal ize at high speed for from 1 to 2 hours. Make 
smears of the sediment and stain as above. 

Guinea pig inoculation should also be resorted to 
when in doubt. The sputum is injected intraperi- 
toneally. If the animal is first given a strong radia- 
tion with the X-ray it will succumb much more 
quickly than othermse. 

Cultivator of the tubercle baoillus. 
Petroff egg media: 

Meat infusion glycerin (500 grams of 
meat infused with 500 cc. of a 15% 
solution of glycerin in water for 
21 hours) 1 part 

Beaten eggs (sterilize shells by pour- 
ing boiling water over them and 
break into sterile beaker and beat 
thoroughly. Filter through sterile 
gauze into sterile graduate) 2 parts 

Ifo alcoholic solution of gentian vio- 
let to make a dilution of 1-10,000 
Tube in sterile test-tubes and inspissate for 
three consecutive days, the first at 85 deg. 
C till solidified and on the two remaining 
at 75 deg. C for one hour. 
An equal quantity of sputum and 



134 

mixed and incubated for 30 minutes to digest the 
former. Neutralize ^^'itll N/HCl and centrifugalize 
at liigli speed for 10 minutes. Inoculate the sedi- 
ment on to a few Petrolf tubes and seal with par- 
affin. Seven to ten days are required for growth. 
The gentian violet inhibits the growth of other 
organisms. 

( Method of isolating the organism from the blood. 
Dr. Mildred C. Clough, J. H. H. Bui., Dec, 1917, 
page 303.) 

10 to 20 cc. of the patient's blood are hemolysed 
in sterile distilled water and centrifugalized at high 
speed for 1% hours. Three-fourths of the sediment 
is planted upon a blood agar slant, which is then 
sealed with paraffin to prevent drying. A growtli 
appears after incubation of 7 to 20 days. The other 
fourtli is inoculated into a guinea pig. 

II. Pneumococcus. Pneumococci are divided into 
four groups, in accordance with their serological 
reactions. See Monograph of the Kockefeller Insti- 
tute for Medical Research No. 7, October 16, 1917. 

Tyi)e I. Causes about 33.3 %_of the cases of lobar 
pneumonia. The disease runs a severe source. The 
organism is practically never found in normal 
sputum. 

Type II. Causes about 13% of the cases of lobar 
pneumonia. The disease runs a severe course. The 
organism is practically never found in normal 
sputum. 

Tj^pe III. Causes about 13% of the cases of lobar 
pneumonia. The disease runs a most severe course. 
The organism is found in about 28.1% of normal 
persons. 

Type IV. Causes about 20.3% of the cases of 
lobar pneumonia. The disease usually runs a mild 
course. The organisms are found in about 18.2% 
of noa'mal persons. 



135 

Types 11-a, lib and li-x are found in about 1S.27(; 
of normal persons. 

Isolation of the pncumococcus and determination 
of group. 

1. Mouse inoculation. Obtain a specimen of 
sputum as free from saliva as possible; wash in six 
changes of sterile salt; grind a piece the size of a 
bean in a sterile mortar, add sterile salt solution 
drop by drop till a homogeneous solution is formed 
that will readily pass through the needle of a small 
syringe. Inject 0.5 to 1.0 cc. of this emulsion intra- 
peritoneally into a mouse. Either wait until the 
mouse is dead or test by peritoneal puncture for 
the presence of pus, and kill if pus is found. In 
either case wash the peritoneal ca\'ity out with 
4 to 5 cc. of sterile salt solution after making pre- 
liminary smears and cultures on blood agar plates. 
Make a homogeneous suspension of the peritoneal 
wasliings and set up tubes as follows for agglutina- 
tion : 



TuLe 


1 


2 


3 




4 




5 


Put 


0.5 cc 


of suspension into c 


\ach 


of^ tubes, 






O 


Q 


Q 




Q 








if 

o 1 


, No. 2 serum 
undiluted 
0.5 cc 


, No. 2 serum 
1-20, 0.5 cc 








'a 


Ivpe 1 . . . . 


+--1- 


— 


— 




— 


Di 


s solved 


Tvpe II . . . 
lia, III) IIx 




+ 


++ 




— 


Dissolved 
Dissolved 


Tvpe III . . 


— 




— 




+ 


Dissolved 


Type IV... 


— 


— 


— 






Di 


s solved 


( Incubate 


' for 1 


hour at 37 


deg. C.) 











136 



Precipitin ieM. For this test tlie peritoneal wash- 
ings are centrifngalized until the superuatent fluid 
is water clear. The clear tluid is pippetted off and 
the following set-up made: 



Tube 12 3 4 

Put 0.5 cc of supernatent fluid in each tube. 



Tvpe I — 

Tvpe II . . . ++ 
lia, lib IIx — 
Tvpe III.. — 
Tvpe IV... — 



u: 


zn 


Ul 


CD 


o 


<x> 


o Si i-s 


1— 1 i-S 


1— 1 i-j 


gM 

^ ^^^ 


S3 


^^3 


"n? 


on ? 


o? 


P- to 


o to 


Ci Jj3 


++ 


++ 





+ 








(The precipitin reaction usually occurs at 
once. If it does not, incubate.) 



2. Sputum cultures. Obtain a specimen of sputum 
as free from saliva as possible and wash through 
six solutions of sterile salt solution. A blood-tinged 
flake is the one of choice. After washing the flake 
place a small portion of it upon a blood agar plate 
and break it up Avith a platinum wire bent at a 
right angle. Streak three agar plates with the wire 
without reinoculation. Incubate for 24 hours and 
then look for small colonies with a green zone about 
them. Pick colonies, inoculate broth tubes, and 
carry out agglutination test as given. 

3. Precipitin test in the urine. This test is often 



137 

positive within 12 lioiirs after the initial chill and 
remains positive for some days. When it is posi- 
tive it furnishes a rapid and accurate method of 
determining the group of the organism. For this 
test 0.5 cc. of urine are placed in each of three test 
tubes. To the lirst tube is added 0.5 cc. of Group 
No. 1 serum undiluted; to the second, 0.5 cc. of 
Group Xo. 2 serum undiluted, and to the third, 0.5 
cc. of Group Xo. 3 serum undiluted. If a precipi- 
tate does not come down immediately, incubate at 
37 deg. C. for one hour. The presence of the pre- 
cipitin reaction in the urine indicates a severe in- 
fection and is of bad omen, especially if it increases 
from day to day. 

4. Avery's method. (Jour. A. M. A., Vol. 70, Xo. 
1, Jan. 5, 1918, page 17.) This method is based 
upon the fact that carbohydrates and blood proteins 
when added to suitable media accelerates the growth 
of the pneumococcus, and also that bile dissolves 
the organism. 

Special media for the test: 

Meat infusion broth, 0.3 to 0.5 acid to 
phenolphthalein (sterilized in arnold 
sterilizer on three consecutive days) . 100 cc. 
20% glucose (sterile) 5 cc. 

Defibrinated rabbit's blood (sterile) 5 cc. 

Tube media in small tubes about 4 cc. to the tubo. 

A kernel of sputum the size of a bean is selected 
and washed in six changes of sterile salt solution, 
emulsified in broth and inoculated into one of the 
tubes of special media. Incubate at 37 deg. C. for 
five hours and streak a blood-agar jDlate for the 
isolation of the organism and subse<|uent confirma- 
tion of type. Remove the blood cells from the spe- 
cial media by slow centrifugalization. Remove 3 cc. 
of the bacterial emulsion to another centrifuge tube 
and add to it 1 cc.of sterile ox bile. Incubate till 



138 

the solution of the piieuiiiococci has taken place and 
perform the precipitiu test, using 0.5 cc. of serum 
and bile solution. If ox bile is not obtainable, per- 
form the agglutination test after the cells have 
been removed. 

5. Krumwiede and Valentine's method. (Jour. 
A. M. A., Vol. 70, No. 8, Feb. 23, 1918, page 513.) 

This method is based upon the fact that many 
sputums are comparatively rich in soluble antigens, 
and these antigens are not destroyed by heating to 
boiling. 

From 3 to 10 cc. of sputum are placed into a test 
tube, Avhich is then placed into, boiling water till 
the albumins are coagulated ; that is, if the specimen 
is a suitable one. Break up the coagulum with a 
platinum Avire and add just enough ]N^/]S"aCl to 
carry out the test after it has been centrifuged. 
In some instances no saline is necessary, for suffi- 
cient fluid separates to carry out the test. After 
the coagulum has been broken up agitate it in the 
saline and place again into boiling water for a few 
minutes to extract the antigen, shaking gently. Cen- 
trifugalize and use the supernatent fluid for the 
test. 

Place 0.2 cc. of the undiluted anti-pneumococcus 
serum in narrow tubes and upon each layer an equal 
quantity of the supernatent fluid. Place in a water 
batli at 55 to GO deg. C. and observe in several min- 
ute^\ If a great quantity of the antigen is present 
in the sputum, a ring y\Hl be observed in a short 
time, but if snmller quantities are present, longer 
incubation will be necessary. The advantage of this 
test and of the other tests is to determine the group 
of the organism and the employment of serum in 
tlie treatment should it be Group No. 1. 

HI. Meningococcus. See monograph by Simon 
Flexner on ''Mode of Infection, Means of Prevei;- 



139 

tion, and Specific Treatment of Epidemic Menin- 
gitis," the Rocli:efeller Institute for Medical Re- 
search, 1917. ''The meningococcus enters and leaves 
the body bv way of tlie nasopharyngeal membrane." 

Mode of idcntificatiou. The West tube is used to 
swab tJie nasoi)harynx. Tliis tube consists of a glass 
tube about 7 mm. inside diameter and bent at nearly 
a right angle at one end. A copper wire carrying 
a cotton swab at one end and a loop on the other 
is inserted into the tube, which is then plugged at 
both ends and sterilized. The nasopharynx is 
swabbed by inserting the glass tube up behind the 
soft palate, then pushing the cotton swab out against 
the pharyngeal wall and swabbing it, and finally 
pulling the cotton into the tube again and with- 
drawing the whole tiling. The object is to prevent 
saliva from getting on the swab, which is destructive 
to the organism. The inoculated swab is then run 
over a series of three plates of sheep serum agar, 
which should be made as follows : 

Melted meat infusion agar with a plus 0.4 
to phenolphthalein and cooled to 50 
deg. C. 100 cc. 

Dextrose 1 % 

Sheep serum 1 part, distilled water 3 parts 

(sterilized at 15 lbs. for 10 minutes) 20 cc. 

Avoid chilling the ])lates and incubate at ">7 deg. 
C. for from IG to 20 hours. 

A medium more favorable for growth is made as 
follows : 

Nutrient agar melted and cooled to 50 

deg. C. 100 cc. 

Sterile rabbit's blood 5cc laked in sterile 

distilled water 40 cc. 20 cc. 

The colonies of the meningococcus are small, deli- 
cate and their outlines fade away into the medium. 

Make smears and stains of susi)icious colonies 



140 

and transfer to laked-blood or sheep sernra agal' 
slants. The meningococcus together Avith M. catar- 
rhalis, flavns and phar^ngis-sicctis are gram nega- 
tive. Incubate the slant inoculations for 24 hours, 
and then emulsify in salt solution and subject to 
the following agglutination : 

Polyvalent 1-50 1-100 1-200 1-500 1-1000 1-2000 
Serum 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. 

Emulsion 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. 

Incubate at 55 deg. C. for 16 hotirs and read. 
Any culture which is agglutinated in a dilution of 

1-200 and ferments glucose "and maltose with acid 
production, but does not ferment saccharose, is 
considered provisionally as meningococcus and the 
person from whom it Avas isolated is regarded as a 
carrier. 

Some differential points between meningococcus 
and other gram negative organisms of throat: 
Micrococcus flavus : Colonies velloAv and opaque ; 
indiscriminate agglutination, agglutinated by 
normal horse serum in a dilution of 1-50 and 
by polyvalent serum in a dilution of 1-100 or 
slightly higher. 
Micrococcus caturrhalis : Exerts no action on glu- 
cose, and no agglutination in higher dilutions 
of specific sera. 
Other indefinite gram negative micrococci: Fer- 
ment saccharose. 
Olitsky method for the identification and isola- 
tion of the meningococcus. (Jour. A. M. A., Jan, 
19, 1918, A^ol. 70, Xo. 3, page 153.) 

Tins method takes adA^antage of a fluid medium 
Avhich serAes to eliminate other organisms resem- 
bling the meningococcus and reduces the time nec- 
essary for tlie identification to about 12 hours. 



141 

Medium: Glucose broth, 1% (made from 
veal infusion and having acidity of from 
I)lus 0.5 to 0.7 phenolphthalein ) • 100 cc. 

Sterile, clear, unheated, normal horse serum 5 cc. 

Tube this medium in 8 or 10 mm. tubes, about 
1 cc. to the tube. Suspicious colonies are fished 
from a plate inoculated with the nasopharyngeal 
secretion of a suspected carrier and are seeded into 
these tubes, a colony to a tube. The tubes are then 
incubated 12 hours, and at the end of this time a 
great many negatives can be eliminated. 

Organisms which must be eliminated : 

1. Micrococcus flavus, crassus, pharyngis-siccus 

and unclassified gram positive bacilli will 
show firm agglutination below and slight 
turbidity above. 

2. Bacillus influenzae will not grow for the 

want of hemoglobin. 

3. Micrococcus catarrhalis grows with a dense 

turbidity, and often shows a pellicle on the 
surface. 

4. The gram positive staphylococci grow with 

dense turbidity, show agglutinated masses 
in the sediment, and often have a pellicle. 

5. Streptococci grow with a clear or turbid 

supernatent fluid, but show an agglutinated 
sediment. 
The meningococci give a faint turbidity and a 
slight sediment forms which emulsifies uniformly 
when the tube is shaken. The suggestive positive 
tubes are separated from the definitely negative 
ones, and to the former is added 0.1 cc. of a 1-10 
dilution in 0.85 saline of a high titer polyvalent 
antimeningococcus serum. Incubate the tubes at 
37 deg. C. for two hours in the water-bath and the 
tubes containing meningococci will show definite 
agglutination, and those which do not will remain 



142 

luicljaiiged. From the positive tubes cultures can 
be obtained for fiirtlier identification. 

\y. Diphtheria bacillus. It is important to re- 
meiiiber tliat tliere are organisms in the thvoat of 
h-altliy persons wliich have the morphological char- 
acteristics of tlie diphtheria bacillus, but which pro- 
(luci: no toxin, tlie>e being the diphtheroids; also, 
that one examination of a diphtheretic throat may 
give negative results: hence, upon the ability to 
produce toxin should rest the final diagnosis of the 
organism and one examination should not suffice 
in sus])icious cases. 



P 



/< 



Diphtheroid 

The throat is swabbed Avith a small piece of cot- 
ton and the surface of a serum agar plate is streaked 
with it. Incubate from six to eight hours when 
the diphtheria colonies will be visible and contami- 
nating organisms will not. Make smears from colo- 
nies and stain w^ith Loffler's methylene blue. Stained 
specimens of the cultivated bacillus show the typical 
beaded appearance Avith clubbed ends. For more 
careful study use Neisser's stain. 

V. Bacillus mucosus capsulatus. This gram neg- 
ative non motile bacillus varies from coccoid forms 
to longer bacilli. They are surrounded by a large 
capsule which is easily demonstrable. They groAv 
easily on plain agar, which growth is mucoid and 
sticky. They often cause a A^ry fatal broncho or 
lobar pneumonia J the sputum of Avliich is slimy and 
stickA\ 



143 

^^T. Tiitiueiiza bacillus. This is a very short, mod- 
erately thick, gram negative bacillus which grows 
singly in pairs or sometimes forms threads. It has 
2 polar bodies which make it resemble a gram neg. 
diploccns. It is a frequent secondary invader in 
respiratory and pulmonary infections, such as 
chronic bronchitis, bronchiectasis and tuberculosis. 
The orbanisms grow best on blood agai*, upon which 
the colonies appear as small, colorless dewdrops. It 
has not yet been proved to be the cause of influenza 
epidemics. 

Avery's influenza .media : 
Delibrinated blood, centrifugalized and cells 

resuspended in amount of broth equal to 

original volume of blood 1 cc. 

Agar (sterile) 95 cc. 

Sodium oleate 2% (neutralized and auto- 

claved) 5 cc. 

This media is said to inhibit other organisms of 
the throat and to enhance the growth of the influ- 
enza bacillus. 

VII. Spirochaeta pallida. This organism is some- 
times found in the mouth in association with syph- 
ilitic lesions there. It must be differentiated from 
S. dentalis, S. buccalis and S. refringens. In gen- 
eral it may be said that under the dark Held illumi- 
nator these other spirochaetes have a much livelier 
movement than the pallida, which hardly moves out 
of the field. It has a lashing motion, a spinning 
motion about its long axis and a slight backward 
and forward motion. It is usually easy to identify 
the pallida from these characteristics. 

YIII. Spironema vincenti. This organism is found 
in Vincent's angina in association with a cigar- 
shaped bacillus. They are both readily stained with 
dilute carbo-fuchsin and gentian violet. 



144 
Sputum in various diseases. 

1 . Lobar pneumonia due to the pneumoeoccus. The 
course of the disease can be followed by the type 
of sputum. It is blood tinged for the first three or 
four days and mucoid in consistency. After this 
blood cells disappear and it assumes a rusty appear- 
ance from altered blood pigments. This lasts until 
after the crisis, when it becomes muco-purulent, and 
later serous. Occasionally one sees x3neunionia 
without sputum at all. In some cases a green color 
is noted in the later stages of the disease, due to 
altered blood pigments. In pneumonia due to the 
B. mucosus capsulatus the sputum is slimy and 
sticky and very tenacious. 

2. Tuberculosis. This disease may have almost 
any kind of sputum. As a rule, in the early stages 
there ma^^ be little or no sputum; later it may be- 
come mucoid or mucopurulent and blood streaked. 
On microscopical examination one may find the acid- 
fast organisms and elastic tissue. 

In chronic tuberculosis the amount of sputum 
varies from little to tremendous amounts. It may 
be bloody, mucopurulent, or purulent. 

In ulcerative tuberculosis one finds sputum of 
a feweetish odor, blood clots, a great deal of elastic 
tissue^ caseous lumps which do not give a bad odor 
on ci'ushing, and on microscopical examination one 
mav find all kinds of contaminating organisms. 

Tn fibroid tuberculosis one may have no sputum, 
'^ it may be mucoid or mucopurulent. 

'■, Ab^cesse^. The sputum is abundant, cheesy, 

u'^c^'ou . and masses of blood may be present. 
)cca ionally one finds masses of lung tissue and 
elastic tissue. 

4. Gangrene. The sputum is the same as abscess, 
except that the odor is characteristically very foul 
and penetrating. 



145 

5. Infarction. Immediately after the accident the 
sputum is stringy and mucoid and blood streaked, 
or there may be a marked hemoptysis. The sputum 
soon becomes rusty and "prune juice'- in character, 
which change comes on sooner than in pneumonia. 

C). Chronic passive congestion. In this condition 
tlie sputum is thin and abundant. It may be slightly 
rust;\'. On microscopical examination one finds 
"heart-failure cells," i. e., alveolar epithelium con- 
taining blood pigments. 

7. Asthma. There is no sputum in the early 
stages of the attack, but when the attack breaks 
pearls of Lannec (mucoid globules) make their ap- 
pearance. On careful examination one finds, also, 
Curslimann's spirals, Cliarcot-Leyden crystals and 
eosinophiles. 

8. Bronchitis. There may be no sputum or there 
may be present pearls of Lannec and Charcot-Leyden 
crystals. 

Fihri)ioifs bronchitis. In this type of bronchitis 
there may be fibrin casts of the bronchi. 

Purulent hionclntis. The sputum has a mucoid 
base with a yellowish appearance from the presence 
of i)us cells. 

riccrativc hronchitis. Epithelial cells remain un- 
changed. Goblet and ciliated cells appear occa- 
sionally. Tissue fragments and blood may be pres- 
ent. 

Chroidc hroucliitis. The sputum is usually thin, 
may be tinged Avith blood, and may contain Dit- 
trich's plugs. In the later stages of the disease the 
sputum may become foul, abundant and muco-puru- 
lent. 

D. Bronchiectasis. The sputum usually occurs 
periodically in large amounts and has a fetid odor. 
In tlie early stages it is thin and watery, but later 
(Continued on Page 146) 



146 

it may resemble the sputum iu abscess, except that 
there is not so much pus. Cartilage, elastic tissue, 
clots of blood and tissue masses may be present. 
Its separation into three layers, viz., top, brownish 
froth ; middle, clear and mucoid, and bottom, gran- 
ular ; is not characteristic for this disease, but occurs 
whenever there are large amounts of sputum. 

10. Pulmonary oedema. This is usually a termi- 
nal event, but frequently occurs after too vigorous 
thoracentesis. It may start during the tapping and 
may last from 5 minutes to 24 hours. Huge amounts 
of fluid are given otf. It is a safe rule not to draw 
off more than 1500 cc. at one tapping. 

STOOLS. 

Constituents of stools. 

I. Food remnants. These are undigestible or un- 
absorbed. Xormally, there are some and it is diffi- 
cult to draw a line between the pathological and the 
normal under various conditions. When an excess 
of meat fibres occur, the condition is called creator- 
rliea ; and when an excess of fat occurs, the condi- 
tion is called steatorrhea. It is important to be- 
come familiar with vegetable cells in order not to 
confuse them with animal parasites or their ova. 

Fat. Fat occurs as soaps and fatty acids and 
sometimes as neutral fat. If it occurs as neutral 
fat, it is yellow and clear ; while as fatty acid, it is 
wiiite and glistening. Soaps usually occur as the 
insoluble calcium and magnesium soaps, but in rapid 
peristalsis the soluble sodium and ]30tassium soaps 
nuiy occur. Neutral fats indicate the absence of 
lipase. Fatty acid increase indicates an excess of 
fat in the diet over that Avhich can be absorbed or 
hyperperistalsis. In the decreased secretion of bile 
an excess of fats occur also. 



147 
DIFFEREXTrATTOX OF FATS, FATTY ACIDS & SOAPS. 



Test. 
Heat 
Ether 


Xeutral fat. 
Melted 
Dissolved 


Fatty acid. 
Melted 
Dissolved 


Soap. 




Sudan III 


Stained 


Crystals 
Globules 




+ 





Osmic acid 
Scharlack R. 

H,0 


1 Stained 



Stained 



1 




Xa. & IC. dis- 
solved 
Ca. & :M.g-. un- 
' dissolved 


KOH 
Carbol fuchsin 


+ 
+ 








Soaps can be broken np with acetic acid and tbcn 
stained with Sndan I IT. Some fatty acids with a 
h)w nieltino- ])oint appear in globnbir form and stain 
with Sudan ITT. 

Sugar and starch. These are not nsnal. Occa- 
sionally tliey come thronj^h in a cellubir envelope. 
Test with iodin Avhich turns starch granules blue, 
and Benedict's solution which is reduced by sugar. 

Tf. Tnte^stinal tract secretions. 

Bile. Occult bile never seen in the adult. To de- 
termine the presence of bilirubin or hydrobilirubin 
emulsify about 2 or :> cc. of the stool in a concen- 
trated solution of mercuric chloride. Allow to stand 
24 hours and examine microscopically. Green sig- 
nifies the presence of bilirubin ; red indicates hydro- 
bilirubin. 

UrobUui. This is normal in certain amounts, but 
large amounts are pathological. To determine its 
presence use Schlessinger's test as follows : Make an 
acid-alcohol extract of the stool, add a few drops of 
Lu gal's solution, 1 or 2 cc. of XH^OH, and an equal 
volume of an alcoholic solution of zinc acetate. 
Filter and examine the filtrate for a greenish fluo- 
rescence. Spectroscopic examination of the intesti- 
nal fluid normally is positive in dilutions up to 1 to 
9,000. In higher dilutions than this it is patho- 
logical. 



148 

Mucus. When mucus is abundant it means catar- 
rhal inflammation. In a disease resembling asthma 
one may get complete casts of the colon, which are 
usually passed between stools. To test for mucus 
is usually unnecessary. 

Ferments. These are usually tested for in order 
to determine whether the pancreas is functioning 
normally or whether the pancreatic secretion is en- 
tering the intestine. Since trypsin and lipase are 
more easily destroyed by bacteria and each requires 
actiyation to show its maximum efliciency, and also 
since proteolytic action of the intestinal bacteria 
may complicate the tindings, the study of the dias- 
tase of the stools is probably the best means of 
obtaining this information. 

Method of performing test: 

1. The patient is given a light meal and a high 

enema the night before. 

2. At 7 A. M. the next day, 750 cc. of milk are 

given. 

3. At 7.30 and 8.00, half an ounce of Epsom salts. 

4. At 8.30, a glass of Avater containing a tea- 

spoonful of bicarbonate of soda. 

Save all stools up to 2 P. M. in a vessel contain- 
ing 2 ounces of toluol and keep in the ice-chest or 
cool room. If less than 400 grams of cc. are ob- 
tained, an enema of a pint of water is given. From 
400 to 1,100 cc. are to be expected. 

Titration of the diastase: Dilute the stool with 
enough water to make 3,000 cc. Dilute 2 cc. of this 
Avith 48 cc. of isotonic salt, which gives a dilution of 
1 to 25, and then centrifugalize to clear. Set up 
tubes as folloAvs : 

1 2 3 4 5 6 

1 cc stool 1 cc stool 1 cc stool 1 cc stool 1 cc stool 1 cc stool 
1-25 1-50 1-100 1-200 1-400 1-800 

Add 2 cc of 0.1% starch solution, after dilutions 



149 

are made, to each. Incubate at 37 cleg. C. for half 
hour and add a few drops of a 1% solution of iodin 
to each tube. Blue shows the presence of undi- 
gested starch. 
Calculation : 

% cc. of 1-25 diluted stool digests 2 cc. of 0.1% 

starch. 
1 cc. of 1-25 diluted stool digests 4 cc. of 0.1% 
starch, or 0.4 cc. of a 1.0% starch solution. 
1 cc. of undiluted stool digests 10 cc. of a 1% 
starch solution. Tlie unit is the digestion of 1 cc. of 
a 1% starch solution by 1 cc. of undiluted stool. 
The minimum of normal is 600 units. 

(See article by Dr. Brown in Boston Med. and 
Surg. Jour., :N"ov. 30, 1916, Vol. CLXXV, pages 775 
to 784.) 

Schmidt and Strasburger diet for pancreatic effi- 
ciency : 

1. Morning: 500 cc. of milk and 50 grams of 

zweibach. 

2. Forenoon: 500 cc. of oatmeal gruel com- 

posed of: 

Oatmeal 40 gm. 
Butter 10 gm. 

Milk 200 cc. 

Water 300 cc. 

3. Noon: 125 gm. (raw weight) of chopped beef, 

broiled rare and 20 gm, of butter. 

250 gm. of potato broth composed of : 

Mashed potato 190 gm. 

Milk 100 cc. 

Butter 10 gm. 

4. Afternoon : Give same as for forenoon. 

5. Evening : Give same as for dinner. 

This diet should be given three days or longer in 
order to obtain stools in which it is present. In 



150 

pathological conditions there will be food remnants 
of all kinds. 

ITT. Decomposition products. 

Gasses: H,S, CH^, ^\ H, and CO,, which 
are the products of fermentation and 
putrefaction. 

Crystalline bodies : Tndol and skatol. These 
give the feces their characteristic odor. 
IV. Bacteria. These make up about one-third by 
weight of the stool. 

A. Those ^^'hich normally occur: The majority of 
these belong to the colon group, among which the 
more common ones are: B. coli, including B. fecalis 
alkaligenes, and B. acidi lactici ; B. lactis aerogenes, 
B. subtilis, B. proteus vulgaris, etc. A few strep- 
tococci and staphylococci are sometimes found. 

B. Those Avhich occur under j)athological condi- 
tions. 

1. Bacillus typhosus. This organism occurs in 
the stools of typhoid patients and of typhoid car- 
riers. One of the best ditferential culture media for 
identification is Endo's media, which is made, ac- 
cording to Robinson and Rettger's modification, 
as follows : 

Agar 25 grams . 

Meat extract 5 grams 

Pepton 10 grams 

Water 1000 cc. 

Dissolve the agar, pepton and meat extract, and 
autoclave at 15 pounds pressure for 30 minutes. 
Filter through cheese cloth and cotton, add 10 cc. 
of 10% sodium carbonate, adjust reaction to # plus 
0.1 phenoli)hthalein, put in 100 cc. containers and 
autoclave at 10 pounds for 10 minutes. 



151 

When ready to use, add to each 100 cc. of agar: 
20% lactose solution (Arnoldized) 5 cc. 

10% freshly prepared anhydrous sodium 

sulphite sol. (sterile) 1 cc. 

Saturated alcoholic fuchsin (basic) 0.5 cc. 

Pour plates and allo\y to harden without the 
covers upon them. 

# Plus 0.1 phenolphthalein means the addition of 
0.1 cc. of N/HCl to 1000 cc. of the medium after the 
neutral point of the solution has been determined 
with phenolphthalein as indicator. 

The basic fuchsin is colorless in an alkaline me- 
dium, but turns red in acid solution. Since the 
typhoid bacillus does not ferment lactose, the 
typhoid colonies will remain colorless, while the 
colon colonies will turn red because the colon bacillus 
ferments lactose. 

An emulsion of the stool is made in isotonic salt 
solution and a loopful of the emulsion is transferred 
to an Endo plate. With a bent wire the surface of 
the plate is streaked, and, without flaming, a second 
plate is treated likewise. Incubate 24 hours and 
pick colonies. In order to be relatiyely sure that a 
colony picked is a typhoid one, microscopic aggluti- 
nation can be done in the following way: A low 
dilution of anti-typhoid serum is made (1-100), and 
one drop of this is placed upon a clean slide. A 
drop of salt solution is placed upon the same slide 
near the drop of serum, and in it an emulsion of 
one of the suspicious colonies is made. The two 
drops are now coalesced, and within 2 or 3 minutes, 
if the colony picked is one of typhoid, deflnite clumps 
can be made out. One must be sure in this pro- 
cedure to haye the drops large enough to prevent 
drying, which would give false readings. If the 
colony picked gives agglutination, the remainder is 
inoculated upon agar for further identification. If 



152 

one should titrate specific sera with typhoid, para- 
typhoid (a) and paratyphoid (b), one could deter- 
mine the dilution of each, wliich Avould agglutinate 
the organism for Avhich it was specific and not those 
which it agglutinates in lower dilutions. By this 
rapid slide agglutination one can, by properly dilut- 
ing the sera, sometimes determine which of the 
typhoid group of organisms he is dealing with. 

2. Dysentery bacilli. These are a group of bacilli 
which are resj)onsible for some forms of dysentery 
and which are differentiated by sugar reactions and 
agglutination tests. Their isolation can be accom- 
plished by the use of Endo's media or brilliant green 
media, for which see Park and Williams Bacteri- 
ology. These are short gram negative rods, with 
little or no motility. The colonies are not as large 
nor as opaque as the typhoid or colon and most of 
the groups are colorless on Endo's media. They 
also appear later than the foregoing. By use of 
the polyvalent serum they can be detected by macro- 
scopic slide agglutination, and then transferred to 
other media for more careful study. In making 
cultures it is desirable to pick the bloody flakes 
of mucus, 

3. Tubercle bacillus. These are occasionally swal- 
lowed and must be excluded. The smegma bacillus 
must also be differentiated, which is . not alcohol 
acid-fast. Particles of blood-stained mucus are most 
likely to show the organisms. The antiformin 
method is not very satisfactory unless the organisms 
are present in large numbers. 

4:. Cholera spirillum. This organism can usually 
be diagnosed from morphology and serum reactions. 
It can grow in a media too alkaline for the growth 
of other organisms. In fluid media it seeks the 
surface where oxygen is most abundant. It liquifies 
gelatin slowly, unlike S. metchnikovi. 



153 

Y. Animal i:>arasites. See section on parasitology. 
VI. Foreign bodies. 

1. Gall stones. Tliese may be large or small. 
Stones as large as the gall bladder itself may ulcer- 
ate into the intestine and cause obstruction. Smaller 
stones must be differentiated from cartilage, insolu- 
ble soaps, enteroliths and fecal masses, >Yhich can 
be done by crushing, dissolving in ether and allow- 
ing to crystallize out. In the case of gall stones, one 
will find cholesterin crystals. 

2. Intestinal sand. This is mucus impregnated 
with calcium salts. These smaller particles may 
become matted together into larger enteroliths. 

3. Objects sTvallowed. Coins, buttons, safety pins, 
hair, etc. 

4. Objects left in the abdominal cavity during 
operation. Clamps, sponges, knives, etc., may ulcer- 
ate through the bowel and be passed per rectum. 

A'll. Tumor fragments. If these come from any 
distance they are digested beyond recognition. Oc- 
casionally they aid in the diagnosis of tumor. 

VIII. Pus cells. A few occur normally. When 
in very great numbers they may arise from ruptured 
abscess. When seen in clumps they may indicate 
some ulcerative process, such as dysenter}', ulcera- 
tive colitis, syphilis, carcinoma, tuberculosis or 
typhoid. 

IX. Blood. That coming from the mouth must 
be excluded. If the blood is at the bottom of the 
stool its source must be low down in the intestinal 
tract; if on top, its source is higher up. If blood 
comes from high up in the intestinal canal, it will 
be dark and give the stool a characteristic tarry 
appearance, although its source may be high up and 
appear dark red if there be rapid peristalsis. Blood 
from the stomach gives a tarry black appearance. 

Blood occurs in any ulcerative condition of tlie 



154 

iutestinal tract, such as typhoid, ch^sentery, carci- 
noma, ulcer, etc. It also occurs as a result of rup- 
ture of blood vessels into the stomach or intestine, 
as in Banti's disease, aneurism or hemorrhoids. 

Tests for Mood. The best is the guiac test. Make 
a watery emulsion of the stool, add a few drops of 
glacial acetic acid, extract T\dth ether and perform 
in the same manner as with the urine. The benzi- 
dine test can be carried out in the same manner. 

A good preliminary test is the following : 

Make a smear of the stool upon a glass slide, and 
before it dries add a solution of benzidine in glacial 
acetic acid plus an equal volume of hydrogen-perox- 
ide. The absence of a green color shows that no 
blood is present. If the material turns a green color, 
a more accurate test, such as the above, should be 
performed, 

X. Crystals. 

1. Fatty acid. Long or short needles singly 

or in groups. 

2. Calcium phosphate. Wedge shaped in 

rosettes, or singly. 

3. Magnesium phosphate. Rhombic plates. 

4. Triple phosphates. Coffin-lid crj^stals. 

5. Calcium carbonate, sulphate and oxalate. 

(See urine.) 
G. Calcium lactate. Radiating needles in 
sheet-like masses. Found in children on 
milk diet. 

7. Cholesterin. Usually occur as steps, one 

superimposed upon the other. In doubt- 
ful cases test with concentrated sulphuric 
acid. The color changes from yellow to 
blood red, violet, green and, finally, blue. 

8. Charcot-Leyden crystals. These are color- 

less, double-pyramid crystals. 



155 

9. Hematoidin crystals. These are reddish yel- 
low, rhombic plates, groups of needles or 
amorphous masses. 

Color of stool. The normal color is brownish, due 
to h^Tlrobilirubin. Bilirubin occurs in children, 
but never in adults. The color also depends upon 
exposure to the air and the character of the diet 
as well as medication. Milk gives a light-brown 
color; meat, dark brown; bismuth, black; senna and 
rhubarb, yellow, and calomel, a green, which is due 
to bilirubin not changing into hydrobilirubin. Blood 
gives all shades from bright red to black. Clay- 
colored stools occur in pancreatic disease due to 
excessive amount of fat, the action of bacteria re- 
ducing bile pigments, or the absence of bile due to 
the occlusion of the bile duct. Yellowish-green 
stools often occur in hypermotility of the intestine. 

Odor of stool, formally it depends upon the 
presence of indol, skatol, methane and hydrogen 
sulphide gas. The odor is most marked on a heavy 
meat diet and less marked on a vegetable or milk 
diet. It is almost lost during fasting. An excess 
of fermentation over putrefaction will give a sour 
odor. In some cases of severe dysentery- and carci- 
noma of the large bowel the stool has an intensel}^ 
disagreeable odor. 

Number and amount. There are great individual 
variations. There may be a normal number of 
stools and yet be constipation. Xormally from li*0 
to 250 "vams are excreted a da v. 



156 
STOOLS IN DISEASE. 
There are no characteristic stools in disease, but 
the stools of some diseases are of some diagnostic 
help. 

1. Obstructive jaundice. (Due to stone in the 
common or hepatic duct, carcinoma at the head of 
the pancreas, or duodenitis with temporary closure 
of the common duct.) The stool is strictly acholic 
and clay-colored if the obstruction is complete and 
fat globules and crystals are seen. Clay-colored 
stools resembling this are sometimes found where 
no obstruction to the bile excretion exists, but where 
bilirubin appears in the form of a leukobase and 
can be demonstrated by the bilirubin test. Clay- 
colored stools associated with nausea and vomiting 
and jaundice give a complete picture. If there is a 
history of colics, search, at least for three days, for 
stone. If one is found, confirm by crushing, extract 
with ether, evaporate and examine for cholesterin 
crystals. 

2. I*ancreatic disease. (May be associated with 
stone shutting off the pancreatic duct.) The stools 
are ver}^ large and have an abundance of neutral 
fat. They may resemble vaseline or freshly-fallen 
snow. They may be odorless or sour. Besides the 
great quantity of neutral fat, fatty acids are found 
and great quantities of undigested meat fibres. 

3. Carcinoma of the stomach. There is usually 
associated hyperperistalsis, but occasionally anti- 
peristalsis. In the cases with hyperperistalsis there 
occurs a copious diarrhea. If no blood is present, 
they are pale or yellow in color, but if blood is 
present, they are brown to black. The odor is 
usually foul. On microscopical examination one 
finds undigested meat fibres more frequently in this 
disease than any other. 

4. Carcinoma of the rectum. The stool may be 



157 

normal in size, shape and consistenc^N', or, if the 
growth has caused a stricture, they may be ribbon- 
like. They may show a coating of blood if ulcera- 
tion has taken place, and mucits. Occasionally tis- 
sue fragments are found. 

5. Annular carcinoma of the sigmoid. The groAvth 
may constrict the lumen and cause obstruction. 
There is usually constipation, distension, much gas, 
and there may be hyperperistalsis. Metastasis oc- 
curs late and the prognosis is usually good. 

6. Amyloid disease. Abundant and frequent 
stools with little odor, ]!^o tenesmus, pain, blood 
nor mucus. Diarrhea continuous. 

7. Hypoacidity. Foul-smelling, abundant diarrhea, 
with meat particles, much mucus, and blood if asso- 
ciated with carcinoma. Often a little hydrochloric 
acid will relieve condition. 

8. Mucus colitis. The cause may be due to a for- 
eign protein, much like asthma. Charcot-Leyden 
crystals and eosinophiles are found. 

9. Sprue. There is irritation of the whole gastro- 
intestinal tract. There is stubborn diarrhea and 
pain. 

10. Metallic poisoning. (Arsenic and mercury.) 
These drugs cause a gaj^tro-enteritis. Mercury is 
excreted in the colon and causes an intense irrita- 
tion and watery stool. 

n, StricLiire of the rectum. This may be due to 
any of a number of causes: syphilis, carcinoma, and 
sometimes a congenital malformation. Kibbon stools 
are characteristic. If there is ulceration, as in 
carcinoma and lues, there will be an excess of mucus 
and pus. Eibbon stools always indicate rectal ex- 
amination. 

J 2. Constipation. There is a diminution in the 
number of stools, large appetite, a feeling of depres- 
sion, and usually headache. This is more common 



1<8 

and cliionic in women. A decrease in the nnniber 
c. stools may be due to impaction of fecal masses 
in tlie rectum. In many cases these can reached 
Avith the linger and dislodged or broken up. 

1.'). ^[egalo-cohni. (Hirschsprung's disease.) 

There is a congenital weakness of the wall of the 
colon. The bowels may move once a week, once a 
uiontli, and one case is reported of once a year. 
The-c patients present all the signs of constipation. 

14. Ty|>hoid. This is associated frequently with 
con ti])ation, especially in the early stages. During 
ilu stages of ulceration profuse watery and foul- 
siiulling stools occur. They may be yellowish-green 
in coh)r and give rise to the term "pea soup stools." 
Hemorrhages are frequent which are usually pre- 
ceded by oozing and the appearance of occult blood. 
Clinically, this indicates the cessation of hydro- 
therapy and feeding. Typhoid cultures are easily 
obtained. 

15. Cholera. The stools are usually profuse with 
an abundant watery discharge, although moderate 
cases show only a moderate amount of diarrhea. 
Flakes in mucus, rice-like in appearance, give the 
term "rice-water stools." 

16. Amoebic dysentery. This sometimes runs an 
intermittent course. There are periods of intense 
diarrhea, followed by periods of normal stools and 
even constipation. Amoebae are foUnd in the patches 
of bloody mucus. 

17. Tuberculosis. There is a great variation in 
the stools, which depends upcn the site of the lesion. 
In tabes mesenterica there is an interference with 
absorption, and one finds an excess of fatty acids 
and soaps in the stools. This is unlike pancreatic 
disease, where an excess of neutral fat and fatty 
acid occur. Dietary indiscretions lead to great 
diarrhea. 



J 



159 
A. OUTLIXE OF ROUTINE FOR MAKING QUAL- 
ITATIVE EXAMINATIONS OF BLOOD. 

I. Cleaning glass ware (slides and cover slips), 
a. Gj-oss cleaning — several methods. 

(1) Wash with soap and water, then with 
much clean, hot water (never allow 
the water to cool till all the soap is re- 
moved), followed by distilled water, 
finally put in 95% alcohol (may be put 
into ether or chloroform after alcohol). 

(2) Soak in acid mixture (cone, nitric acid 
or a mixture of sulphuric acid and po- 
tassium bichromate) for 6 to 24 hours, 
then wash thoroughly in clean water, 
then distilled water. Finally run 
through two thorough washings with 
95% alcohol and put in ether or chloro- 
form (ether may be omitted — keep in 
alcohol — closed vessel) . 

b. Fine cleaning. 

(1) Keep in alcohol (ether or chloroform), 
and when needed polish with a clean 
cloth (old linen preferable) absolutely 
free from grease and dust. Ex. unfold 
an old but clean and ironed handker- 
chief — use the inside surface which no 
linger has touched. 

(2) Take from alcohol (ether or chloroform) 
and polish, keeping them in a clean, dry, 
well-closed receptacle until used. Ex. 
A closed glass dish. (Avoid Avooden or 
pasteboard boxes, as fragments fall from 
such materials.) 

(3) Never hold with fingers, always use 
clean forceps to handle glass ware. 

(4) Dust off with clean camel's hair brush 
before us^ing. 



160 



(5) It is oCteii advantageous to blow across 
glass ware just before placing blood on 
it — care must be exercised that no parti- 



cles of saliva fall on glass. 



1 1, flaking smears. 

a. Preliminary details. 

(1 ) I^e glass Avare cleaned in manner sug- 
gested under T. Cover glasses must be 
square ( round will not do) ; cover glasses 
must not be too thick, as oil immersion 
cannot be focused upon preparation ; size 
22 mm. preferable, thickness Xo. 1 essen- 
tial. 

(2) Glass Avare must be flat — avoid concave 
surfaces — blood will not spread. 

( .") ) Dip blood sticker in alcohol before using 
(never flame sticker — dulls point). 

(1) Wash skin with alcohol and dry before 
sticking. Alcohol frees skin from grease 
and is antiseptic ; drying prevents blood 
drop from spreading over skin. 

(5) Avoid CA'anosed areas and aA^oid cyano- 
sis by squeezing area Avhich is to be 
stuck, in order to make the blood floAA\ 
Blood examinations from such areas are 
useless for many purposes. 

(()) Stick deep enough to bring from 2 to 4 
drops of blood— preferably without the 
assistance of any pressure. While any 
pressure is undesirable, a slight amount 
is sometimes necessary. 

(7) Wipe off the first drop — use the second, 
Avhich is more representative of actual 
blood picture. 

b. Actual smearing. 

(1) CoA^er slip method. 

(a) With instruments. 



161 

1 . Plokl cover slip Xo. 1 in cross bill 
forceps. 

2. Hold cover slip Xo. 2 in clean, 
plain forceps. 

.*). Brush the cover slip Avith a clean 
camel's hair brush to remove any 
lint or dust. 

4. Place drop on cover slip Xo. 2. 
Drop should be size of small 
black-headed ])in. Let it reach the 
cover slip by capillary attraction. 
Xevei' touch skin with cover slip. 

5. With drop on cover slip Xo. 2, 
j)lace cover slip Xo. 2 on cover 
slip Xo. 1 in such a maner that 
tl'.e dro]) is sj)read without caus- 
ing bubbles. (Ex. Let cover slip 
X'^o. 2 come down so that cover 
slip Xo. 1 touches edge of drop 
first and gradually touches whole 
drop — or let the drop reach the 
first cover slip by capillary at- 
traction). 

0. Let drop spread until it has 
almost stopped spreading — expe- 
rience is needed for this. 

7. Pull cover slip in an absolutely 
horizontal numner. Any tendency 
to a vertical pull will ruin the 
preparation. (Holes in the smear 
will result.) 

8. Place preparations (smear side 
up) on a clean paper and allow 
them to dry in the air. 

9. Protect smear from insects, ants 
and flies especially, as they will 

' quickly ruin smear. 



162 

(b) Without instruments. 

Cover slips may be bandied by 
the lingers instead of Avith forceps 
in making smears provided tbe 
following precautions are ob- 
served : 

1. Use forceps to take cover slips 
from the clean container. 

2. Hold cover slip between fingers 
so that only the edges are touched 
and never the surface of the glass. 

3. Cover slip No. 1 is held in left 
hand, usually between thumb and 
forefinger. Place drop on cover 
slip Xo. 2, Avhich is held in right 
hand, and then proceed to make 
the smear as directed above, with 
the exception that the pulling is 
done by holding the cover slip 
with the fingers rather than with 
forceps. 

(2) Slide method (use of slides instead of 
cover slips). 

A drop, larger than the one used for 
cover slip method, is placed on a slide 
and drawn across it so as to make a 
smear. Various methods for spreading 
are suggested. 

(a) By means of a second slide, prefer- 
ably with a beveled edge and of a 
width less than the slide on which 
the smear is to be made (i. e., break 
off a corner of a slide to make it nar- 
rower)., 

(b) A small glass rod (w^idth less than 
slide), to which another glass rod 
has been fused, to serve as handle, 
in such a way that the combination 



163 

looks like a T. The cross-beam of 
the T is used as the spreader. 

(CI (Mgarette paper, hat pius, long 
needles, or plain glass rods may 
also be used as the spreading agent. 

(d) The spreader (whichever method 
suggested being used) may be placed 
to the left of the drop, and the blood 
in this way pulled across to the 
right, or 

fe) The spreader may be made to touch 
the drop from the right and the 
drop pulled across the slide to the 
right. (This method is to be pre- 
ferred.) 

(f ) Tlie thickness of the spread can be 
varied by changing the degree of 
angulation of the slide and spreader. 
(X.B. — The drop should be placed 
well to the left of the slide, so that 
a long spread may be pulled to the 
right). 

c. Criteria for good smears. 

(1) Smooth, even spreads, with R. B. C. 
lying flat (never in rouleaux)). Their 
edges may touch, but there must be no 
overlapping. 

(2) At least 8 such areas (low power) with- 
out holes and without streaks are re- 
quired to constitute the minimal re- 
quirement for a good smear. 

d. Relative merits of cover slip and slide 
methods. 

( 1 ) The cover slip method gives a much bet- 
ter distribution of W. B. C. and is the 
method necessary to use in making dif- 
ferential W. B. C. counts. 



164 

(2) The slide method gives a good distribu- 
tion of K. B. C. The large W. B. C. 
(polymorphonuclear and large mono- 
nuclear) are pushed to the edges and 
the lyphocytes remain scattered through 
the spread. This makes satisfactory dif- 
ferential counting impossible. When E. 
B. C. are to be examined for parasites, 
the slide method is superior to the cover 
slip method, inasmucli as more fields are 
available for study and the E. B. C. dis- 
tribution is as good as Avith the cover- 
slip method. 
III. Making stained preparations, 
a. With Wilsoji stain. 

(1) The stain. A modified Eomanowski 
stain — a polychrome methylene blue- 
eosin stain. (For details of making it 
see Emerson, Webster, etc.) 

(2) Technique of applying stain. 

(a) Use freshly made smear for stain- 
ing; smears 2 to 4 days old do not 
stain so Avell as those stained very 
soon after making. 

(b I Place preparation with smeared sur- 
face up (smeared surface has not 
the gloss of the clean glass surface) 
in staining forceps on the edge of 
a table or on a cork for support in 
such a manner that it may easily be 
taken up Avith a pair of forceps. 

(c) With a dropper drop 6 to 8 drops of 
Wilson stain on the smear, being 
careful to avoid shaking the bottle 
of stain before using it in order to 
keep stain free from any precipitate 
which may be present. Let the stain 



165 

remain on the smear 60 sec. (using 
second hand of watch for accurate 
calculation) ; then 

(d) Add the same number of drops of 
distilled water, and let the prepara- 
tion stand an addition 4 min. (by 
the watch) ; then 

(e) Taking the cover slip with forceps 

(preferably staining forceps to pre- 
vent possibility of dropping cover 
glass) and holding it carefully in 
a perfectly horizontal manner so 
that the scum which has formed on 
the surface may not touch the glass, 
float off rather than wash off the 
scum with a stream of water (pref- 
erably distilled), which is at first 
run very slowly, and then more 
briskly so as to free the smear from 
all traces of excess stain. All this 
time the cover slip is held abso- 
lutely horizontally. Washing should 
take from 5 to 8 seconds. 

(X. B. — 1. For staining, do not 
hold smear with any forceps used for 
liulling smears — forceps used for 
pulling smears must be kept abso- 
lutel}^ clean. 

2. Each fresh supply of stain re- 
quires a new formula for stain and 
water combination. In general equal 
numbers of drops of stain and water 
are used.) 

(f ) After washing is completed, the 
cover slip, still held in the staining 
forceps, is tilted and the lower edge 
touched to a blotter, so that the 



166 

excess of water is quickly drained 
off. 

(N. B. — If the cover slip be held 
with any forceps other than stain- 
ing forceps, great care must be ex- 
ercised to j)revent fluid collected at 
the forceps' tip from running over 
the preparation and streaking it. If 
any such forceps be used, it is best 
to tilt the cover slip immediately 
after washing, in such a manner 
that the excess of water on the 
cover slip runs toicard the forceps. 
Remove the cover slip from the for- 
ceps and holding it in the hand, 
drain off the excess of water by 
touching an edge to a blotter. (Pref- 
erably that edge held previously by 
the forceps.) 

(g) After washing, the smears are dried 
in one of the following ways : 

1. By air drying : a. Generally by 
placing the smear against some sup- 
port and letting one edge rest on a 
blotter, b. By waving it gently in 
the air, holding it with either for- 
ceps or finger (touching only the 
edge of the cover slip if the finger 
method is employed). 

2. By blotting : Place preparation 
between layers of fine blotting paper 

(it must be absolutely free from 
dust). Apply light pressure to the 
upper layers of the blotting paper 
to facilitate drying. Then pick up 
the preparation and remove it to 
a dry place, and again apply light 



167 

pressure. Be careful not to push 
the smear along the blotter nor to 
press too heavily, for holes and 
streaks in the preparation will be 
the result. 

(N. B. — The staining is thought 
to be better if the blotting method 
is employed, but many good smears 
have been ruined by slight negli- 
gence in the manner of blotting.) 
(h) After drying the preparation (if it 
be a cover slip), mount it in Can- 
ada balsam {acid free) in one of the 
following ways : 

1. Preferably smear side down as 
the preparation is then protected 
from insects and any acid or alkali 
in the air. 

2. Smear side up if the cover slip 
is too thick to permit focusing the 
oil immersion when mounted smear 
side down. 

(N. B. — If slides are used instead 
of cover slips, the technique is iden- 
tical except that the preparation is 
not mounted, and for examination 
oil immersion is applied directly to 
the surface of the smear.) 
(l\) Criteria for a good stain. 

R. B. C. — Are of a buff color, neither 
lemon nor red. 

Platelets — Are well stained — nuclear 
purple blue stain, with the architecture 
plainly visible. 

W. B. C. — Are stained as follows : 

Polymorphonuclears. 

P. M. N. — Nucleus — Deep purple, retic- 



168 

ular, chromatin pronounced, more poly- 
morplious than |)olynuclear. Grannies — 
May or may not be seen ; vary in size ; 
pink or yiolet. rrotoplasm— Faint pink. 

r. M. E. — Nucleus — Larger than P. M. 
X., fewer lobes; takes lighter purple 
color ; reticulated. Granules — Large, 
round or oyal; bright red; tend not to 
oyerlie nucleus. Protoi)lasm — Faint pink. 

P. M. B. — Nucleus — Chromatin scanty, 
stains light purple. Granules — Large, 
yary in size; jiurple to black; generally 
some oyerlying nucleus. Protoplasm — 
Faint pink. 

Lymphocytes. — Nucleus — Large, round 
or oval ; slightly notched, chromatin pro- 
nounced, deep purple ; clear zone outside. 
Granules — Normally none; old cells (?) 
sho\v azure granules ; red yiolet ; yary in 
size ; few to a cell. Protoplasm — Scanty, 
crescentic ring; homogeneous sky to 
deei) blue; slightly reticulated. 

Large Mononuclears. — Nucleus — 
Large, oyal, indented, horse shoe, kidney 
or yery irregular shape ; chromatin poor ; 
light blue or purple color; generally ec- 
centric. ProtoiDlasni — Abundant, often 
irregular, clear, reticulated, pale blue 
(reticulated nodosities giye granular ap- 
pearance). Granules — None (azurophil- 
ogranules frequent). 

Malarial parasites are beautifully 
stained with Wilson stain. The areas 
between the cells must be clear and free 
from all suggestion of stain. The cells 
must stand out with distinctness T\ith 
jio suggestion of hazy edges. There must 



169 . 

be no precipitate present. 
(4) Common pitfalls in staining with Wil- 
son stain. 

(a) Precipitate on the preparation. 

1. Due to: a. Faulty washing, l)y 
not holding preparation horizontal 
and floating otf scum, thus permit- 
ting the scum, which ahvavs forms, 
to touch the smear, b. Permitting 
dust to settle on the smear. 

2. Prevented bv: a. Holding the 
preparation horizontal all during 
the washing and learning to play 
the stream of water in washing to 
the best advantage, b. Keeping the 
smears clean during tlie interval 
which elapses between pulling and 
staining. 

(b) An indefinite serum-like stain be- 
tween the cells, due to insuflicient 
washing. 

(c) Tearing preparation by improper 
blotting. 

(d) Deterioration of stain supply due 
to: 

1. Acids kept in the same locker. 

2, Water from mixing pipettes or 
putting stain in bottle waslied witli 
water. 

b. With Jrinio' stain. 

(1 I The stain. A simple methylene blue- 

eosin, alcoholic staiu. (For details see 

Emerson, Webster, etc. i 
(2) Technique of a])plying stain, 

(a) Freshly made smears stain better 
than those 24 to 48 hours old. 

(b) Staining, washing, blotting and 



170 
mounting are carried out in a man- 
ner like tliat described under Wilson 
stain with the following differences : 

1. Place 6 to 8 drops of stain on 
the smear and leave for 2 min. (use 
watch for timing) ^ then add the 
same number of drops of water and 
leave for an additional 2 min. (use 
watch), wash and dry. 

(N. B. — With each fresh supply 

of stain a new formula for the stain 

and water combination, as well as 

for the time relation, is necessary). 

(3) Criteria for a good stain. 

E. B. C. — Are of a darker color 
than the K. B. C. with Wilson stain, 
pink rather than buff, although it 
is possible and advisable to have 
them look as much like the R. B. C. 
of the Wilson stain as possible. 

Platelets — Stain rather jDOorly — a 
pale blue. 

W. B. C. are stained as follows : 
The nuclei are not so well stained 
as with Wilson stain, but granules 
stand out well. 

Polymorphonuclear — Nuclei blue, 
but distinctly paler than with the 
Wilson stain. Neutrophile granules 
a deep pink. Eosinophile granules 
a very deep pink. Basophile gran- 
ules purple blue. 

Lymphocytes — Nuclei a moderate- 
ly pale blue, protoplasm tinged with 
blue. 

Mononuclears — Nuclei paler blue 
than those of the lymphocytes, proto- 
plasm a faint blue* Azurophilic 



171 

granules show less proiiiineiitly than 
with the Wilson stain. 

^Malarial parasites are not well 
stained. 

The intercellular areas are clear 
and shoAV no stain. 
(4) Pitfalls in using Jenner stain. 

These are almost absent. The chief 
difficulty is in giving the nuclei a deep 
enough blue stain. Improper stains show 
the nucleus to have a faded-out bluish 
tinge. By changing the water and stain 
combination and by washing more quick- 
ly the nuclei can be made to take a bet- 
ter stain. 
c. With EhrUch stain. 

(1) The stain — a complex triacid aqueous- 
alcohol stain. Do not shake the bottle 
before using. 

(2) Preliminary details : 

(a) Old smears stain better than fresh. 
Ex. smears 5 to 10 days old are bet- 
ter than tliose 5 to 10 hours old. It 
is advisable to have 15 to 25 smears 
of the same age when an Ehrlich is 
to be stained. 

(b) Before staining, smears must be 
fixed by heat in the following man- 
ner : 

1. Heat a copper bar for 30 to 10 
min. in a place free from draughts, 
so that the flame will not be shift- 
ing. (X. B. — Place flame under 
point of bar.) 

2. At the end of that time, with 
a dropper having a small bored 
point, drop a few small drops of 



172 

water (3 to 4) on the bar in an 
etfort to find the spheroidal i)oint. 
(Spheroidal point equals point on 
bar where water rolls off in glob- 
ules.) Let at least 5 min. elaj^se be- 
tween trials, so that the heat lost 
by the application of the water will 
be surely regained. 

3. AYhen the spheroidal point has 
been determined by repeated tests, 
draw a chalk line across the bar at 
that place. 

( N. B. — Inaccurate determination 
of the spheroidal point is to blame 
for many poor Ehrlichs.) 

4. Place preparation, smear side 
up, outside the spheroidal point, 
with the edge closest to the flame 
exactly on the line. The method is 
carried out as follows : 

Fix a smear 20 sec, another one 
30 sec, still another 40 sec, on up 
at intervals of 10 sec, until 90 to 
150 sec (Devise a method for care- 
fully differentiating the variously 
heated smears so that in staining no 
confusion will arise as to the lixa- 
tion time of any particular smear, 
for ex. 20 sec. or 90 sec.) 

5. In general, the older the smears 
the shorter the required time of 
heating. Ex. smear 10 da^^s old 
may be well fixed at 30 sec. ; smear 
1 day old may be well fixed at 150 
sec. or more. 

(3) Actual staining. 

(a) Place the stain on the smear and 
let it remain 5 min. At the end of 



173 

that time pour the stain hack into 
the t)ottle, and wash off the adher- 
ing ainonnt of stain in the sink. 
Dry and blot as directed under the 
other staining methods. 

(Ehrlich stains are not easily 
ruined in the staining and washing, 
but are generally spoiled by poor 
fixing.) 

(4) Criteria for a good Ehrlich. 

(a) The cells should stand out clearly 
with no intercellular stain. 

(b) The K. B. C. should be buff, without 
the slightest suggestion of any red 
color, and without being a lemon 
yellow. 

(N. B. — Smears Avhich are under- 
fixed or markedly over-fixed have a 
reddish color in the K. B. C. Smears 
which are moderately over-fixed 
have lemon color in the K. B. C.) 

(c) The W. B. C. stain as follows : 

P. M. X. — Nucleus — Blue green or 
robin's egg blue; no structure visi- 
ble. Protoplasm — Faint pink. Gran- 
ules — Lilac, if correctly fixed ; red 
from short fixation. 

P. M. E. — Nucleus — Light green 
color. Protoplasm — Generally none 
seen. Granules — Dark red or crim- 
son. 

P. M. B. — Nucleus — Light green, 
reticular. Protoplasm — None seen. 
Granules — No stain, often seen as 
colorless vacuoles. 

Lymphocytes. — Nucleus — Light 
blue green. Protoplasm — ^Light pink 



174 

or violet, often very faint. Grannies 

— None seen. 

Lartie Mononnclears. — Xnclens— 

r\iint bine or green. Protoplasm — 

Fink or light violet. Grannies — 

None seen, 
(di Platelets are not stained. 
( e ) Malarial parasites are not stained. 
(."")) Creneral tecliniqne nsed in staining with 
Ehrlich. 
( a I From 15 to 25 smears ; select 3 or 4 

of the best and lav them aside. 

(b) Take the less good smears and rnn 
through the various times for fixing 
a Irea d v su gges ted . 

(c) Stain these, and after mounting ex- 
amine them carefnlly with oil im- 

. mersion, and note the following 
points : 

1. Under-fixed smears Avill have 
reddish staining K. B. C, often with 
stained intercellular spaces. The 
W. B. C. will have a dirty appear- 
ance with granules not standing out 
distinctly. 

2. Well fixed smears will have the 
R. B. C. of a buff color (neither 
yellow nor red). The W. B. C. will 
stand out distinctly with neutroph- 
ilic and eosinophilic granules well 
stained and standing out sharply 
against a clear unstained proto- 
plasm. 

8. Over-fixed smears will have the 
R. B. C. lemon color. The granules 
in the polymorphonuclear white 
cells Ayill not be clear cut, and if 



'175 

stained will be seen lying in a 
stained protoplasm. There is 
a smudgy look to the polymorpho- 
nuclear cells. The mononuclears 
are often so faintly stained as to 
be missed. 

4. If still further over-fixed, the 
K. B. C. lose their lemon color, and 
again take on a reddish hue. 
(d) Having discovered a well-stained 
smear, note the heating time for it, 
and then fix any number of good 
smears (of the same age) for a sim- 
ilar time. 

(N. B. — The need of again deter- 
mining accurately the spheroidal 
point is evident since by placing 
these goods smears at a point which 
is no longer the spheroidal point, 
they will be ruined.) 
d. General points with regard to stained blood 
preparations. 

(1) Be careful to mount cover slips in a 
neufral halsam, if any acidity is pres- 
ent (as frequently occurs) the color 
will fade at a rate proportional to the 
degree of the acidity, the nuclear ele- 
ment, particularly, being attacked. 

(2) Keep the preparations away from bright 
sunlight, from acid or alkaline fumes. 

(3) After using oil, remove it with xylol. 
(N. B. — Never attempt this if the smear 
has been freshly mounted.) 

lY. Differential Counting. 

The cover slip method must be used for this 
as follows : . 
a. With a mechanical stage count across and 



176 

up and down over the good areas of the 
spread. Be careful to use such a technique 
that the same areas will not be counted 
twice. 

b. .'iOO W. K. C. must be counted. In order 
to get the true proportion it is necessary 
to include in this nund^er brolvcn cells and 
undertermined cells as well as those which 
can be classified. 

c. A W. P. (\ count should always be nuide 
at the time a ditferential is counted. It is 
only by this means that relative or abso- 
lute changes in the number of cells is de- 
termined. 

(1. The classiticati(m of cells is as follows: 
(1) Polymorphonuclear neutrophiles (P. 
M. X.). 

The nuclei — irregular, 2 to ^) lobes, 
often appearing actually polynuclear. 
The granules — pink or violet (AVilson). 
pinker (Jenneri, lilac (Ehrlich). 

(X. B. — With Wilson the granules 
may not stand out distinctly an<l one 
sees only the more or less homogenous 
pink protoplasm.) 




(2 1 l^)Iymorphonuclear eosinophiles (P. 
M. E.). 

Tlie nucleus is irregular, generally bi- 
lobed and nmy give the appearance of 
being actually polynuclear. The gran- 
ules are large as compared with the 
neutrophilic granules and are all of the 



177 

same size. They stand out very dis- 
tinctly and stain a deep pinl-c to crim- 
son with all stains. These cells tend 
to be a trifle larger than the neutro- 
philes and are rather fragile. For the 
latter reason they can often be found 
broken witli their granules scattering. 
Eosinophiles are in general recognized 
by the large, constant size of their 
granules rather than by the depth of 
the granular stain. 



5 




(o» Polymorphonuclear basophiles (P. M. 
B.). 

The nucleus is of the size and shape 
of the eosinophilic nucleus, but some- 
times is entirely hidden by the deeply 
staining basophilic (blue) granules 
which completely fill the cell. These 
granules are not stained by the Ehrlich 
stain. 



# 




Wilson Stain Khrlich Stain 

(1) Lymphocytes. 

Small and large types with the size 
of the P. M. N. taken as the arbitrary 



178 

(^livicUng line; lymphocytes smaller 
than a P. M. X. are considered small 
lymphocytes (S. L.). Those as large 
as or larger than the P. M. N, being 
considered as large lymphocytes 

(L. L.). 






«» 



I 



L. Iv. S. L. P. M. N. L. Iv. 

The nucleus is round and takes a 
deep blue stain. The protoplasm stains 
a pale blue (darker than the proto- 
plasm of the large mononuclear) and 
gives an impression of thickness. It 
is sometimes described as waxy (in 
contradistinction to the thin tissue 
paper thickness of the protoplasm of 
the large monos.). The cell is fairly 
regular in outline and is round in 
shape. 
(5) Large mononuclears are large cells 
with a single nucleus, which is round 
or kidney shaped. The nuclear stain 
is lightei' than that of the lymphocyte 
and the nucleus appears less dense. 
In the protoplasm, which is stained 
a pale blue, can be seen the reticular 
nodosities, which may be so marked 
as to give a granular appearance. No 
true granules are ever present, al- 
though the reddish azurophilic gran- 
ules are often found. This cell is pro- 
portionally large, with a relatively 



179 

large amount of protoplasm. Tt gives 
the impression of great thinness. 

(The term transitional is given to 
those cells when the nucleus is kidney 
shaped. It probably represents an 
older type of cell.) 







^nS 



Transitional 

V, Fresh blood examinations. 

a. Technique. 

(1) Place a drop of blood the size of a pin- 
head on a cover slip (procured as for 
making smear). 

(2) Place the cover slip on the convex side 
of a slide in such a manner that the 
drop is spread without bubble forma- 
tion. Let the cover slip remain on the 
slide. 

(3) Study first with the low power, then 
with high, dry and oil immersion. 

b. Criteria for a good preparation. 

(1) The spread must be thin, with the cells 
lying flat and not overlapping. 

c. Common difficulties in making a good, fresh 
blood preparation. 

(1) E. B. C. overlap or lie in rouleaux, 

due to 

(a) Unclean glass ware. 

(b) Too large a blood drop. 

(2) Uneven spread, due to 

(a) .Dirty glass ware. 

(b) Careless spreading of the drop. 



180 
J. Findings in a fresh blood preparation. 
(1) R. B. C. 

(a) Color — Greenish yellow with the 
intensity depending npon the 
amount of hemoglobin present. 

(b) Shape — Ronnd (if lying free T^ith- 
ont touching other cells), with a 
biconcavity, the apparent degree of 
which depends upon the amount of 
hemoglobin content. Abnormalities 
in the shape of the cell as a whole 
constitutes a condition known as 
jwikiJocytosis. 

(c) Size — Diameter of 7.5 mikra ; nor- 
mally there is only the slightest 
variation in size. With noticeable 
variation in size the condition is 
spoken of as anisocytosis. 

Large cells = macrocytes (ap- 
proximately above 9 mikra ^. 

Small cells = microcytes (ap- 
proximately below 6 mikra). 

(d) Degenerations — Due to trauma as- 
sociated with the spreading and to 
the drying of the preparation, de- 
pending, of course, primarily upon 
the inherent fragility of the cells. 

1. Total degeneration. 

The cell shrinks and becomes darker in 
color ; the margin becomes irregular : 
varying numbers of prickly points appear, 
giving the picture of a thorn apple, crena- 
tion. These points Avhen apiDcaring in pro- 
file are readily recognized, but when 
looked straight down upon ma}- give the 
impression of cellular inclusions. 



181 

2. Partial degeiieratiou. 

a. Maragliano bodies — an endoglobular 
degeneration, generally in the center 
of the cell, but frequently at the 
periphery, occurring as a single or 
multiple degeneration in a cell. The 
body is round or elliptical and looks 
like a vacuole. Its size and position 
in the cell often change. Confusion 
arises with nucleated R. B. C. and the 
early stage of malarial parasites. 

b. Bacilliary degenerations — rod-like hya- 
line areas in the cells, with a vibratory 
motion so that the ""area" may move 
through the whole substance of the cell. 
Often confused with bacilli. 

c. Ehrlich^s hemoglobinemic degeneration 
— cells appearing with a dark center 
and a light periphery often giving the 
appearance of a small cell superim- 
posed upon a larger one. The condi- 
tion probably is due to areas of con- 
densed protoplasm with the hemo- 
globin separated from the stroma. 







Pessary Form 

3. Differentiation of degenerations from 
actual inclusions in the E. B. C, such as 
nuclei or malarial parasites, 
a. Changing the focus upon a degenera- 
tion results in a variation in the ap- 
parent size of the degeneration greater 
than that of the containing E. B. C. 



182 

b. Changing the focus upon a nucleus or 
malarial parasite results in no such 
proportional change in size, the nucleus 
or parasite merely becomes more or 
less distinct as the focus is changed. 

(2) W. B. C. 

Colorless round bodies, varying from 
8 to 17 milvra in diameter. The shape 
is irregular, and amoeboid motion may 
occasionally be seen. In the polymor-. 
phonuclear cell the granules may be 
easily distinguished, and eosinophiles 
and basophiles can be differentiated 
from the neutrophiles by the larger size 
of the granules of the former. The 
nuclei appear as hyaline areas ^dthin 
the cells. The mononuclear cells are 
recognized with more difiiculty, inas- 
much as there are no granules. The 
nucleus appears as a round hyaline area. 
The protoplasm is clear. Unless the 
light is well cut down, such cells are 
easily overlooked. 

(3) Platelets. 

They appear as small granular masses 
lying singly or in groups. Because of 
their sticky nature, they are never seen 
floating, but adhere to the glass or to 
corpuscles. 

(4) Blood dust. 

Dancing particles which give the im- 
pression of cocci. They probably rep- 
resent extruded granules from poly- 
morj)honuclear cells. 



183 

JJ. (^)UTLINE OF TECHNIQUE OF QUANTITA- 
TIVE BLOOD EXAMINATIONS. 

I. Blood counting. 

a. Apparatus and use of solutions. (For de- 
scription see Emerson, Ed. IV, page 459.) 

(1) Counting chamber. 

(a) Never wash with alcohol or ether 
as the cement is in this manner dis- 
solved. Clean with a soft cloth and 
cold or lukewarm water (never 
hot). 

(N. B. — The glass platforms on 
the counting chamber are mounted 
in balsam as a cement, hence the 
need of avoiding alcohol, ether, 
xylol, and heat in any form in clean- 
ing.) 

(b) Before using have the counting 
chamber and cover slip so clean that 
Newton's rings appear when the 
cover slip is placed on the slide. 
Any grease, dust or lint mil pre- 
ventthe rings from appearing. 

(2) Blood pipettes. 

(a) Care of the pipettes. 
1. Cleaning, 

a. Fill the bulb three times with 
distilled water, shaking each 
time, emptying and refilling. 

b. Repeat the above procedure by 
filling with 95% alcohol three 
times. 

c. After using alcohol, fill the bulb 
three times with ether. In this 
Avay the pipette will be thor- 
oughly dried and cleaned. If the 

.above x-)rocedure has been prop- 



184 

erlv carried out, the glass bead 
will not adhere to the sidei of 
the bulb and there will be no dis- 
coloration am^Avhere in the j)ip- 
ette. 
d. Never let saliva be drawn into 
the pipettes. Prevent this by 
either using a force pump for 
cleaning pipettes or at times re- 
moving the rubber tubing and 
blowing out the accumulated 
saliva. 
2. Take all precautions against break- 
ing the point of the pipette. The 
slightest nick which enters the bore 
renders the pipette useless because 
of the resulting inaccurac}^ in dilu- 
tions. 
(b) Use of the pipettes. 
1. K. B. C. 

a. Blood is drawn to point 0.5 with 
great accuracy. 

Hayem's Solution 
(for diluting r. b. c.) 
Mercuric chloride 0.500 gm. 

Sodium chloride 1.00 gm. 

Sodium sulphate 5.00 gm. 

Distilled water 200.00 cc. 

b. Diluting fluid (Hay em's solu- 
tion) is draAvn to point 101 with 
equal accuracy (resulting dilu- 
tion in the bulb of the pipette is 
1 :200). 

c. With a finger placed over each 
end of the pipette, shake the pi- 
pette for 5 min. with a trans- 
verse rather than a longitudinal 



185 

motion. (Shake the bulb to and 
I'ro across the bnlb — a longitudi- 
nal motion results in an uneven 
dilution by slmking cells into 
ca])illarY tube of pipette.) 

d. After sufficient shaking expel 2 
or o drops from the pipette ( rep- 
resenting the fluid which re- 
mained in the bore and was not 
mixed in the bulb ) and use the 
third or fourth drop to place in 
the counting chamber. 

W. B. C. 

a. Blood is drawn to point 0.5 wilh 



Turk's Solution 




(for diluting w. b. c.) 




1% Aqueous gentian violet 


1 cc. 


Glacial acetic acid 


1 cc. 


Distilled water 


100 cc. 



b. Diluting fluid (Turk's solution) 
is drawn to point 11 with equal 
accuracy (resulting dilution in 
the bulb of the pipette is 1 : 20 ) . 

c. Shake and place drop in count- 
ing chamber as described above. 

3, If a second preparation is to be 
made from a i^ipette and during the 
interval the pipette has been laid 
aside, it is necessary to repeat the 
5 min. of shaking, inasmuch as the 
cells will have settled and no accu- 
rate count could be made without 
another thorough shaking, 
b. Technique of placing the drop in the count- 
ing chamber.- 



186 

(1) Siugle counting chamber. 

From a pipette place a drop in 
the manner described above on the 
central raised ring of glass. This 
drop must be of such a size as to 
cover the entire ring after the cover 
slip is placed over it, but must not 
be large enough to cover the moat 
and spread over the surrounding 
raised glass platform. It is per- 
missible, but undesirable, to have a 
little fluid enter the moat. With 
the drop placed, lower the cover slip 
over it in such a manner that no 
bubbles are formed. If bubbles oc- 
cur, wash the counting chamber and 
repeat the attempt. Newton's rings. 

(N. B. — Bubbles cause an uneven 
spread of cells.) 

(2) The Burker Double Counting Cham- 
ber (with two central raised glass 
platforms, making it possible to 
make two preparations simultane- 
ously K Place the cover slip on the 
chamber and see that Newton's 
rings are present — do not remove 
the cover slip. From the pipette 
let a drop run under the cover glass 
over each central glass platform. 
The size of the drop must be gauged 
by practice. It must be sufficient^/ 
large to cover the whole platform 
and yet not large enough to cover 
the moat. No bubbles are permis- 
sible. If they occur, a fresh prepa- 
ration in the counting chamber 
must be made. 



187 

c. Counting cells in the counting chamber. (Re- 
fer to Emerson, AYebster, etc.) 
(1) K. B. C. 

(a) With high-power focus on the cen- 
tral portion of fine ruling. 

(b) Some cells will be found lying out- 
side the specified area, but touching 
the lines of division — count such 
cells when they lie on dividing lines 
to the left or above the section be- 
ing counted. Omit those lying on 
the right or beloAv. 

(c) Begin counting at the extreme left 
— move to the right over the upper 
row of 5 small squares, then pass 
to the next lower row and move to 
the left, then descend another row 
and pass to the right, and proceed 
in this fashion for each of the 5 
rows in each of the 4 corner units. 

(d) Count the 4 corner squares on two 
preparations. 

(e) Calculation. 

1. The area of the fine ruling rep- 
resents 1 square mm. of 1/10 mm. 
depth. 

2. This area is broken up into 16 
subunits, of which number the 
4 corner ones in each of two 
preparations have been counted; 
therefore, 1/2 cu. mm. of diluted 
blood has been counted. 

3. Let X ^ the sum of cells counted 
in the 8 corner units; therefore, 
X = number of cells in 1/20 cu. 
mm. of diluted blood. 

4. In the red pipette the blood was 



188 

diluted 200 times ; therefore, 200 
X = number of cells in 1/20 cu. 
mm. of undiluted blood, or 4000 x 
= number of cells in 1 cu, mm. of 
blood. Therefore, when the 4 
corners in 2 preparations have 
been counted the number found 
is multiplied by 4000. The re- 
resulting figure represents the 
R. B. C. count or the number of 
R. B. C. found in 1 cu. mm. of 
blood. 
(2) W. B. C. 

(a) With the low-power focus on the 
ruled portion of the counting cham- 
ber and pick out the four large cor- 
ner areas of coarse ruling (each 
such area is the size of the central 
finely ruled area and represents 1 
sq. mm.). 

(b) AVith low-power count the 4 cor- 
ner areas and also the whole cen- 
tral finely ruled area — thus count- 
ing 5 sq. mm. on each of 2 prepa- 
rations, or 10 sq. mm. in all. 

(c) Use the same method of including 
those cells which touch dividing 
lines to the left and above and 
omit those lying outside the speci- 
fied area, but touching dividing lines 
to the right and below. 

(d) Begin at the extreme left and work 
to and fro in the manner suggested 
for R. B. C. counting. 

(e) The cells counted in the 10 areas 
(represented by x) will represent 
the number found spread over a 



189 

surface of 10 sq. mm. with a 1/10 
mm. depth; therefore, x ^ number 
of cells in 1 en. mm. of diluted 
blood. 
(f) The dilution in the white pipette 
was 20: therefore, 20x = number 
of cells in 1 cu. mm. of whole blood. 
Thus when the 10 squares have been 
counted, the number of cells found 
multiplied by 20 = the W. B. C. 
count or the number of W. B. C. 
found in 1 cu. mm. of blood, 
d. Kequirements for satisfactory counts. 

(1) K. B. C. 

(a) A satisfactory count requires that 
the difference in the number of cells 
counted in each of the 4 corner 
squares in 2 preparations shall not 
not exceed 25. 

(b) Such satisfactory counts shall be 
made on two successive days, with 
not more of a variation between the 
total counts than 200,000 cells. 

(2) W. B. C. 

(a) A satisfactory count requires that 
the dijfference in the number of cells 
counted in each of the 5 sq. mm. 
areas in 2 preparations shall not 
exceed 8. 

(b) Such satisfatcory counts shall be 
made on two successive days, Tvith 
not more of a variation between the 
total counts than 200. 

Because of the AY. B. C. of an indi- 
vidual vary with bathing, eating, exer- 
cise, etc., it is advisable to make the 
counts on the successive days under con- 
ditions as nearly constant as possible. 



190 





Ex. of satisfiu 


•torv 


counts. 




May 4tli 


May oth 




May 


lOth 


Mav nth 


^^ 


'.B.C. ' ^Y 


.B.C. 




R.B.C. 


Px.B.C. 


Trep. 1 


42 Prep. 1 


32 


Prep 


1 149 


Prep. 1 153 




34 


40 




150 


148 




41 


40 




135 


130 




38 


40 




149 


128 




40 


40 








Prop. 2 


42 Prep. 2 


40 


Prep 


2 150 


Prep. 1 155 




36 


40 




148 


135 




35 


40 




145 


150 




38 


39 




127 


131 




21 


33 
















1153 


1130 




387 


384 




1153 X 4,000 = 4.612.000 




387 X 20 =3 ■; 


'.740 




1130 X 4.000 = 4.520.000 



384X20 = 7,680 
IT. Haemoglobin determinations. 

a. Talqnist's method (see Emerson, Ed, IV, 
page 525, for fnll explanation). 

(1) Teclmiqne. 

With a drop of blood on a piece of 
provided filter paper match its color in 
a scale of standard colors which is to 
be found in the book. 

(2) Difficulties. 

The scale of standard colors does not 
hold its registration of color values ac- 
curately ; age and exposure to light tend 
to fade them. 

(X. B. — If this method is to be used, 
the individual color scale should be 
standardized from time to time by run- 
ning parallel determinations with it and 
a Sahli or Miescher instrument.) 

b. Sahli method (see Emerson for diagram and 
full description). 

(1) Apparatus and its use. 

(a) In order to insure a homogeneous 
shade, the sealed standard tube 
(filled with a standard acid hematin 
susnension) should be inverted sev- 



1^1 

eral times before a determination of 
Hb. is to be made. 

(bl The pipette is filled with blood up 
to the 20 cu. mm. mark (the only 
mark on the pipette). The filling 
must be done accurately and all 
blood adhering to the outside of the 
pipette must be carefully remoyed 
before the pipette is emptied into 
the calibrated tube. 

(c) The calibrated tube, which must be 
clean and dry, is first filled with 
a stock solution of X/10 HCl ex- 
actly to the 10 mark. (This is used 
to lake the blood Avhich is intro- 
duced into the tube and to trans- 
form the liberated haemoglobin into 
acid hematin.) Into this solution 
the pipette containing the blood is 
carefully introduced and the con- 
tents of the pipette expelled by 
means of careful blowing. The acid 
solution is cautiously drawn into 
the pipette and repeatedly expelled 
in order to remoye thoroughly all 
blood from the pipette. The blood 
is allowed to remain in the acid for 
exactly one minute by the watch, 
and then distilled water is added 
until the shade agrees with that in 
the standard tube. 

(N. B. — In mixing the contents 

of the calibrated tube the following 

points are of yalue : 

3. If during the addition of fluids 

the upper part of the tube has 

been kept dry, it is possible, by 



192 

ctireful tilting, to foriii a menis- 
cus across the npper portion of 
the tuhe. When this has been 
acconii)lishe(l the tube may be 
safely inverted and the tlnid^ 
thoroughly mixed. 
2. The fluid in the tube should never 
be permitted to touch linger, as 
a loss of fluid occurs which 
amounts approximately to 1 de- 
gree on the scale, with a result- 
ing inaccuracy in the ultimate 
reading. 
( 2 ) Meihod of taking the readings. 

(a I Allien a reading is to be made, the 
tube should always be placed in the 
stand witli its ground glass back. 
( b ) Let the light come through the back 

of the stand. 
( c ) Readings are best made by daylight. 
Artiticial light makes the ditferenti- 
ation of shades difficult, 
c. Miescher method (see Emerson for diagram 
and full description ) . 

(1) Consideration of points not sufficiently 
emphasized. 

(a) The cells must be thoroughly dry 
and clean before the bottoms are 
screwed in. The groove in the glass 
bottom and top should be oiled each 
time before placing them in posi- 
tion. The floor must be screwed in 
iiglithj, so that there may be no 
interchange of fluids betAveen the 
two sides of the cell. Place dis- 
tilled water in one side of each 
cell and let the preparation stand 



193 

for several minutes to be sure the 
compartment is water tight before 
adding the blood preparation to the 
other side. 

(b) For normal blood a dilution of 300 
is satisfactory. DraAv blood to the 
2/3 mark on the pipette, and then 
till with 0.1% XaoCO.. 

(X. B.— Any trace of XaHCO. in 
the diluting fluid must be avoided, 
as it will cloud the preparation, 
making a satisfactory reading im- 
possible.) 

(e) Shake tlie pipette thoroughly until 
the solution becomes perfectly clear 
and the sliade homogeneous. 

fd) Fill tlie empty side (Avhich has been 
proven to be Avater tight) of both 
the 12 and 15 mm. cells at the same 
time and make readings at once on 
first one and then tlie other prepa-- 
ration. (The pipette contains 
enough of the preparation to per- 
mit of the filling of both the 12 and 
15 mm. chambers at the same time.) 

(e) The readings are made in a dark 
room, prepared for the purpose. A 
candle flame aftords the necessary 
liglit for illumination of the prep- 
aration, and the scale may be seen 
by using a flash light, or turning 
on the electric light momentarily. 
Ten successive readings should be 
made on both the 12 and 15 cu. mm. 
cells. The scale should be turned 
alternately too high and too low 
and the color matched by running 



194 

through the higher shades down to 
the same shade and again by run- 
ning through the paler shades up 
to the same shade. The average 
of the 10 readings is the one taken 
as final. 
(f) The tables of calculations which 
accompany the Mieschers are not 
interchangeable. A preparation on 
a Miescher must be calculated ac- 
cording to the table made for that 
special instrument, 
d. Kequirements in Hb. work. 

On the day on which the R. B. C. count 
is passed (which is the day of the second 
successful K. B. C. count) a Sahli determi- 
nation shall be made and repeated again the 
following day. A difference of 5 is per- 
mitted in the readings on the two days, A 
Miescher reading shall be made on two suc- 
cessive days, the first Miescher shall be made 
on the day of the second Sahli determination. 
Readings with the two cells, both calculated 
for the 15 mm. cells, shall not vary over 2 
points. 

C. ADDITIONAL BLOOD EXAMINATIONS. 

I. Coagulation time. (L^se of Bogg's coagulo- 
meter. See Emerson for full explanations and 
diagram.) 
a. The following points require emphasis : 

(1) Consider the time from the moment the 
drop appears on the skin until the radial 
motion in the drop is seen under the 
microscope. 

(2) Focus with the low power of the micro- 
scope on that part of the drop just 
opposite the blowing tube. 



195 

(3) Blow as lightly as possible on the drop, 
moving only 6 to 10 corpuscles. 

(4) Blow not oftener than at 30 sec. inter- 
vals — more frequently blowing produces 
a vicious cycle and the radial motion 
may never appear. 

b. Requirements. 

(1) Make three determinations in succes- 
sion on the same day. The difference in 
coagulation time should be less than -45 
sec. 
IF. Bleeding time. 

a. Make a finger incision sufficiently deep so 
that a drop of blood 2 mm. in diameter will 
ai3pear spontaneously without any squeez- 
ing. 

b. Take a jnece of smooth filter paper and 
blot oft' the drop every 30 sec. (no nuuiipu- 
lation of the part is permitted). 

c. Divide the number of blots by 2 and the 
resulting figure represents the bleeding time 
in terms of minutes. 

d. Requirements : Carry out this procedure 
once. 

III. Fibrinolysis test. (Goodpasture, J. H. H. 
Bulletin, November, 1914.) 

a. Test based on the ability of the blood in 
certain pathological conditions to digest 
its own clot within a few hours at body 
temperature. 

b. Technique. 

Draw 3-5 cc. of blood into a small, clean 
test tube. Incubate 12 hours at body tem- 
perature. 
(1) Positive test. 

Complete digestion will have oc- 
curred within 12 hours. 



196 



d. 



(2) Negative test. 

Partial digestion or none at all 
within 12 hours. 
Action probably dne to tlie activity of nor- 
mal proteolytic ferments of the blood, oper- 
ating by virtue of a diminution or absence 
of normal anti-proteolytic ferments. 
Fibrinolysis has been found associated 
with chronic liver injury with severely 
impaired hepatic function where a hemor- 
rhasfic tendency exists. 





DIFFERENTIAL W. 


B. C. COUNT. 


Dec. 10, 1918. 






Wilson stain 


W. 


B. C— 8600 


300 Cells 
Cells 


Counted. 


Ehrich 
or Jenner 
Absolute 






Counted. 


Percent 


Number. 


1. 


P. M. N 


. 201 


68 


5818 


9 


P. ME. 


C) 


o 


172 


3. 


P.M.B 


3 


1 


86 


4. 


Lymbho's small 


. 60 


20 


1720 


5. 


Lymbho's large. 


3 


1 


86 


6. 


Large mono's. . 


. 15 


5 


430 


7. 


Transitionals . . 


9 


3 


258 


8. 


Unclassified .... 


. . . . 


•• 


.... 



300 



100 



8600 



197 
CHART FOR SPECIAL BLOOD EXAMINATION. 
Patient's Name. Stain Used. 

Ward or Hospital. Date of Preparation. 

Doctor's Name. Date of Examination. 

I. General Comment on Preparation, Stain, etc. 

IL R. B. C. 

1. Size. 

2. Shape. 

3. Color. 

4. Regeneration forms : 

a. Nucleated R. B. C. ; type; numerous? 

b. Basophilia; punctate or diffuse? 

c. Nuclear particles. 

d. Cabot rings. 

5. Additional Remarks. 
IIL W. B. C. 

1. Apparent number (relative to R. B. C). 

2. Apparent differential. 

3. Presence of abnormal forms : 

a. Myelocytes; type? 

b. Myeloblasts. 

c. Irritation forms. 

d. Fragile W. B. C. ('^smudges") 

e. Pigmented W. B. C. 

4. Additional Remarks. 

IV. Platelets. 

Apparent number (relative to R. B. C). 
Normal; increased; decreased. 

V. Parasites. 

VI. Additional Remarks, General. 

VII. Impression. 

1. Summary of Important Evidence. 

2. Probable Diagnosis. 

Blood Report Number. Name of Examiner. 



198 
HEMATOLOGY. 
Notp: : The following notes on blood are rather 
sketchy in character and are, therefore, of more value 
to those who attended the lectures covering this sub- 
ject than to those who did not. It is hoped, how- 
ever, that even to the latter they may prove to be of 
some value. 

The formed elements of the blood. 
I. Red blood cells (erythrocytes). Normal con- 
sideration. 

1. Embryological origin of the red cells. There 
is a great discussion and difference of opin- 
ion. 

(a) Primary blood islands: 1. Hemoblasts. 
2. Bildungszellen of Koelliker. 

From the outer cells arise endothelial 
cells. From the inner ones the primary 
erytJirohla'Sts arise, which contain no 
hemoglobin and are colorless and nu- 
cleated. All cells are originally of in- 
travascular origin. All are nucleated 
up until the fourth week. By the third 
month only one-eighth are nucleated, 
and at birth none are nucleated. 

Extravascular formation soon com- 
mences, and is especially active in the 
liver, spleen and marrow, the latter be- 
coming more and more the main site. 
Hemoglobin-free cells disappear quite 
early. 

(b) Primary erythroblasts, essentially iden- 
tical with megaloblasts of Ehrlich; 
hence the term "return to embryonal 
form" in anaemias. 

(c) Discussion of the Monistic and Dual- 
istic theory of origin: the discussion 
centers around the point as to whether 



199 



tlie red 


and 


white cells have a common 


origin. 






Dualists, 




Monists, 


Naegeli, 




Shridde, 


Ehrlich, 




Maximow, 


Howell, 




Pappenheim, 


et al. 




et al. 



The main mass of evidence tends to 
establish these points : 

1. Erythroblasts occur at a time much 
earlier than any leucocytes. 

2. Primary cells of Koelliker do not 
form white blood cells, otherwise it 
is impossible to understand why later 
on in the vessels one finds only ery- 
throblasts and neither Bildungs cells 
nor Avhite cells. 

3. Primary erythroblasts and endothe- 
lial cells are sisters. 

4. No direct evidence of transition 
stages of red blood cell into white 
blood cell or the reverse. 
Schridde and Maximow maintain this 

idea : 

Bildungzellen are in reality "large 
lymphocytes. From these there arise 
both white blood cells and red blood 
cells. This is said to be the "primary 
eiythroblast" and may be quite identical 
with the Myeloblast of Naegeli. 



200 

GENESIS R. B. C. 




2. Post foetal formation of erj^throcytes. 

Normally from marrow only. (18(38 Neu- 
mann.) The marrow contains many ripe 
and nnripe cells, most of which are nucleated 
and from 6-12 microns in size. 

Chief variety: 
(a) Megaloblasts — -Definition used here: 
nucleated cell, densely staining, with 
nucleus showing radial arrangement of 
chromatin and as large or larger than 
a normal erythrocyte. 




(b) Intermediates — Nucleated, larger than 



201 
normoblasts. Clinically not important. 

(c) Normoblasts — Nuclei: 1. Dense and pyc- 
notic — old (mature — Howell). 2. Clear 
and radial — young (immature — Howell ). 



Bunting's view : Erythrocytes enter blood 
stream without nuclei. Loss due to Karyor- 
rhexis (a) Karyolysis, (b) Extrusion. 



■♦ 



Karyolysis Extrusion 

Although extrusion actually occurs, it is 
thought that this is not the normal mode. 

3. Consideration of normal erythrocytes. 

(a) Number. The average count stays con- 
stantly throughout adult life. It varies 
from 4,500,000 to 6,000,000. A deviation 
of half a million is of no pathological 
significance, unless associated with a 
change in the color index. At birth the 
count is about 6,000,000. After the first 
few weeks it falls to 4,000,000. After 
this at about the tenth year, or at pu- 
berty, it reaches 5,000,000. After 35 the 
count decreases, and at 60 it is about 
4,500,000. In robust plethoric individ- 



202 

iials the count may be around 0,000,000 
and mean nothing. 

(b) Functions. 

1. Internal respiration. 

2. Lipoid carriers. 

3. Bile pigment (iron). 

(c) Life history. 

There exists a balance between de- 
struction and formation. The normal 
demand upon the marrow causes the 
outpouring of no abnormal forms, 

4, Pathological considerations. 

Pathological changes of very much impor- 
tance concern chiefly: 

1. Variations in the number. 

2. Variations in the hemoglobin content. 

3. Abnormalities in size and form. 

4. Abnormal red cells in the peripheral 
blood. 

5. Abnormal staining reactions. 
G. Vital staining reactions. 

7. Altered resistance of erythrocytes. 
(1) Variations in the number of R. B. C. 
(a) Increased — Polycythaemia, 
Erythremia. 
Physiological. 

1. Early infancy. 

2. Following vigorous exercise. 

3. After hot or cold baths. 

4. High altitudes. 
Pathological. 

1. Concentration of the blood-excessive 
fluid output, or decreased fluid intake. 

2. Prolonged vasoconstriction. 

3. Conditions of chronic dyspnoea. 

4. True polychthaemia (excessive forma- 



203 

lion). Kesistimce o1i cells not in 
creased by test-tube method. 
(bj Decreased counts. OUgocythaemia. 

1. Insufficient formation — aplasia, toxic 
states, etc. 

2. Excessive destruction. 

3. Hydraemia. 

4. Actual blood loss. 

Upper and lower limits of counts. 
Higher limits— up to 9,000,000 (Osier 

found 11,000,0000). 
Average from 1,500,000 to 5,000,000. 
Lower limits — 5,000,000 to 100,000 

(Osier). 
Average for pernicious anaemia — 1,000,- 

000 to 2,000,000. 
Average for secondary anaemia — well 

above 2,000,000. 
(2) Variations in the Hemoglobin content. 

1. Reduction proportionate to R. B. C. 

2. Good R. B. C. count, but tremendous hemo- 
globin reduction. 

a. Chlorosis, 

b. Many chronic anaemias. 
Bone marrow insufficiency. 

Further discussion of the "Color Index" : 
It is important to remember that the color 
index is wholly independent of variations 
in blood volume, vasomotor effects and tlie 
like. It really gives a clear insight into 
conditions of the bone marrow. 
Types : 

(a) Normal — .8 to 1. 

(b) Lower than 1 — Chlorosis, cancer, 
nephritis, hemorrhages. 



204 

(c) Higlier iliaii 1— rernicions auaeniia, 
anaemias of childhood, hemolytic 
anaemias with jaundice. 
(3) Abnormalities in shape and size. 

1. Anisocj'tosis — Variation in size. Not a 
normal event. 

Terminology : 

a. Microcytes, 1-6 microns. 

b. Normoc^^tes, 6-9 microns. 
(Secondary anaemia.) 

c. Macrocytes, 9-12 microns. 

d. Megalocytes, 12-16 microns. 

e. Gigantocytes, 16-20 microns. > 
(Pernicious anaemia.) 

(a) Microcytes — Expression of budding 
process, poor ancestry, small marrow 
cells. Not an expression of ceUular 
youth. 

(bj Normal erythrocj^tes. 

(c) Macrocytes — Swollen cells, never ter- 
ribly large. 

(d) Megalocytes — ■ Characterized by: 1. 
Size. 2. Rich hemoglobin content. 3. 
Essentially absent delle. These are 
really embryonic cells. The}^ occur 
mainly in Pernicious Anaemia and 
anaemias of childhood. They appear 
A\hen demands upon the bone marrow 
are too great. Their appearance de- 
pends not upon the severity of the anae- 
mia, but ui)on the nature and the type 
of the anaemia. 

(e) Gigantocytes. 

2. Poikilocytosis — Variation in shape. 

Poikilocytes may be artificially made by 



205 

pressure or heat. They occur in benign 
forms of secondary anaemia, but in much 
larger proportions in Pernicious Anaemia. 

(4) Abnormal red cells in the circulation. 

1. Microblasts. 

2. Normoblasts. 

3. Intermediates. 

4. Megaloblasts. 

The appearance of these cells denotes 
severe irritation of the bone marrow. They 
are found in: 1. Pernicious anaemia. In 
remissions normoblasts predominate. 2. 
Oftenest in myeloid leukaemia. 3. Chil- 
dren's blood in certain obscure anaemias. 
Embryonic blood building is reverted to 
easier in children. 

(5) Abnormalities in staining. 

1. Anisochromia : Various forms including 
hemoglobinaemic degeneration of Ehrlich. 

2. Polychromasia : a. Anaemic degeneration 
of Ehrlich. b. Polychromatophilic degen- 
eration of Ehrlich (Gabritschewsky ). 

Common occurrence : Common in blood- 
forming organs, embryonic. Occasionally 
seen in normals. 

Considered as a coagulation necrosis by 
Ehrlich and a degeneration. The common 
view held is that they are youthful cells 
and their presence shows that regeneration 
is taking place. Their presence may also 
mean a degenerative process in a sense that 
the marrow cannot hold these cells back. 
They occur in cells subjected to stasis. 
Their appearance does not necessarily run 
parallel with the severity of anaemia nor 



206 

are they necessarily poor in liemoglobin for 
they occnr in cases with a high color index. 

!. Basophilic reacting substances in R. B. C. 
Origin : 

Xuclear remains. 

Xnclear substance not chromatin. 

l*rotoplasmic changes. 

(a) Nuclear particles. 

(b) Howell Jolly Bodies. 

One or two in a cell; round, peri- 
pheral, nuclear stains, common in 
orthochromatic cells. 



(c) Chromatin staubschen. 

End stage of nuclear decay. They 
are bright red, peripheral, minute dots. 

(d) Cabot ring bodies. 

J. Med. Res. 1903. They are bright 
red or bluish with Ehrlich. Appear 
in a variety of shapes. Invariably in 
polychromatic cells. Occur in any 
anaemia, especially Pernicious Anae- 
mia, Leukaemias and Lead Poisoning. 
Never found in blood-forming organs, 



(S)Q 



207 

therefore a pathological change. Kep 
resents especially resistant nuclear re- 
mains ( nuclear membrane ) . Supports 
theory of karyolysis. 

(e) Red basophilia with Giemsa stain. 

(f ) Schuffner's granules. 

These can be seen in fresh R. B. C. 
Occur in Malaria. It is claimed that 
they are not identical with true baso 
philia. 

(g) Punctate Basophilia, common 4'orm. 

Appear as round or angular specks. 
They are absent in Ehrlich stain. Chief 
interest resides in their meaning: 
Regeneration H*), degeneration (?), 
youth (?). They are not seen in fresh 
blood. 



< 



t 



Punctate Basophilia Diffuse Basophilia 

Occurrence: Anaemias and illnesses 
with anaemia. They are absent in 
some anaemias, hence not due to anae- 
mia per se. 

Uncommon in chlorosis. 

Uncommon in adult bone marrow. 

In P. A. not a striking feature. 

Absent in aplastic blood, but pres- 
ent in marrow. 



208 

Coiuinoiily associated with other K. 
B. C. changes. 

Tuberculosis, nephritis, gout. 
They are an essentiallT regenerative 
phenomena. 

Designated here : Ditfnse or Punc- 
tate polvchromasia. 
(til Vital staining of erythrocytes. Really a post 
vital method. 
Methods: 

1. Dry method (not used much). 

2. Widal-Abrami and Brule. 
S(dution and stain : 

Unna's Polychrom. stain 10 -cc 

XaCl .8% ^ 10 cc 

Sod. Oxalate 2% 10 cc 

Draw bloody to 1 in the white pipette 
and solution to 11. Mix and study. 

Blood may be collected in a centrifuge 
tube and then a lilm be made and fixed 
with heat. 

Another method using a pipette is dilut- 
ing the blood with 1/2% Brilliant Cresyl 
Blue in .8% ]S'aCl. Examine wet. 

3. Method of Vaughn. Place a drop of stain 
upon the ear, make puncture through it 
and examine Avet. 

Appearance of cells. 

Occurrence: 1-2% of cells in normal 
blood. Bone marrow, all anaemias. 30-10% 
of cells in the new-born Avithout poly- 
chromasia. Evidence of youth and regen- 
eration. Quite different from basophilia 
according to most. 
(7) Resistance of the red blood cells (Hamburg- 
er) 1902. 



209 
Method of making hypotonic solutions: 
Burette method, usino- H,0 and 1% NaCl. 



% strength Desired. 


1% NaCl. 


H^O. 


Volume. 


.75 % 




7.5 cc. 


2.5 cc. 


10 cc. 


.7 




7.0 


3.0 . 


10 


.65 




6.5 


3.5 


10 


.6 




6.0 


4.0 


10 


.55 




5.5 


4.5 


10 


.5 




5.0 


5.0 


10 


.45 




4.5 


5.5 


10 


.4 




4.0 


6.0 


10 


.35 




3.5 


6.5 


10 


.3 




3.0 


7.0 


10 


.25 




2.5 


7.5 


10 


Q 




2.0 


8.0 


10 


Use .1 to .3 cc 


. of was 


hed R. B. ( 


\ in each dilution. 


Normal minimal resist 


ance is .47 


. Maximal resist- 


a nee is .3. 




z 






Variations in 


resistance : 






1. Decreased 


in hemolytic anaemias. 




2. Increased 


resistance in anaemias a^ 


ith blood 


poisons. 










3. Increased 


resistance under 


iron and arsenic 


therapy. 










4. Results in 


anaemias in general not conclusive. 


Increased 


in P. A 


. and carcinoma. 




Consideration of the White Blood Cell? 


, 



Classification of Normal White Blood CrlJs. 

A. Polymorphonuclear neutrophiles, P. M. N. 

B. Polymorphonuclear eosinophiles, P. M. E. 

C. Polymorphonuclear basophiles, P. M. B. 

D. Lymphocytes. 

E. Large mononuclears, 

F. Transitionals 

One and the same. 
A. Polymorphonuclear neutrophiles. 



210 

T. Description, 

1. Size and shape : 

10-12 microns, but as high as 15 
microns, because they are so easily flat- 
tened out. 

2. Nucleus. 

As many as five, never less than two 
lobes. 

They are joined by fine strands of chro- 
matin. 

3. Protoplasm. 

Granular, takes a slightly acid stain. 

4. Granules. 

Many granules, sometimes overlapping 
nucleus. In the same cell the granules 
are apt to be of the same size. 

5. Function. 

Active scavengers of the body. 

II. Origin of cell. 

Strictly from the bone marrow and in 
adults from the flat bones only, although 
in disease the long bones may also take part. 

III. Normal numbers and variations. 
65-68% of the cells of the blood (in some 

books per cent given higher). 1,500 per 
cubic millimeter. 

IV. Abnormal. 

Increased — in any acute infection, partic- 
ularly in pus formation. Confusing cell- 
metamyelocyte. 
B. Polymorphonuclear eosinophile. 
I. Description. 

1. Size. Larger than P. M. N. (12-11 mi- 
crons). Variations in size^ both large 
and small. 

2. Nucleus. Less multiple division of 
nucleus. 



211 

0. Xucleoli absent. 

4. Protoplasm slightly acid, full of large 
grannies ( 1 micron i which do not over- 
lap nnclens. 

5. Fnnction not known. 

G. Confusing cell-metamyelocvte. 
ir. Origin of cell. 
Bone marrow. 

III. Normal numbers. 
2-4% (average 21/2%). 

IV. Abnormal. 

Diagnostic in several conditions. 

1. Skin diseases. 

l\ Parasitic infections (especially intesti- 
nal). 

3. Blood diseases : 

a. Leukaemias — enormous numbers. 

b. Increase in other anaemias (good' 
omen). 

4. Anaphylactic plienomena in general. 

5. Scarlet fever. 
Decreased : 

1. Frank leucocytosis, "'septic factor/' 

2. Poor bone marrow, regeneration (aplastic 
anaemias ) . 

3. Conditions with lymphocytic increase. 
C. Polymorphonuclear basophiles. 

I. Description of cell. 

About tlie same as P. M. E., except that 
the granules take basic stain, scattered 
throughout the cell and vary in size within 
the same cell. 

Soluble in water. 

Function — nothing known. 

II. Origin — bone marroAv. 

III. Xumber— 1/2 to 1%. 

IV. Xo increase except in myeloid leukaemias. 



212 

D. Lymphocytes. 

I. Description of cell. 

Size and shape: 7 to 10 microns (large 
in children). 

Nucleus — ^picnotic. 

Nucleoli — 1 or 2, never more. Character- 
istically possessing good surrounding mem- 
brane. 

Protoplasm — scant, in fresh looks granu- 
lar. With Komanowski stain has greenish 
blue tint and edge looks thick. 

Few granules varying in size and shape, 
grouped toward the periphery, in about ^ 
of cells. 

Basic stain. 

Never amoeboid. Function little known. 
(Do not give indol blue reaction.) Hinted 
that they play important immunity role. 
(Experiments in cancer and tuberculosis.) 

II. Origin of cell. 

From lymphatic glands, spleen, etc. Al- 
ways of lymphatic origin, never bone mar- 
row. 

III. Normal numbers. 

18 to 30% (average 25%). 

IV. Abnormal. 
Increased : 

1. Lymphoid leucaemia. 

2. Typhoid, malaria, pertussis, tuberculosis, 
syphilis. 

3. Marked vagus stimulation. 

4. Disturbance of endocrine glands. 
Decreased : 

1. Pronounced leucocytosis. 

2. Extreme disease of lymphoid system. 

E. Large mononuclears, 



213 

J'"*. Trausitiouals, 

One and the same cell. 

The origin and the nature of the granula- 
tion of these cells are the cause of much dis- 
cussion. Classed as non-granular cell they are 
really granular. 

I. Description. 

1. Size — largest cells, 12 to 25 microns. 

2. Xuclei — pale, compact, leptochromatic. 
]N^o clearly defined membrane. 

3. Protoplasm — basic, well-defined reticula- 
i tion. 

4. Nucleoli — without staining no nucleoli 
are seen, but with vital staining as many 
as three may be seen. 

5. Granulation — peculiar characteristic 
type. Xo azure or fuchsin granules. 

II. Origin. 

Probably myeloid. There are several 
points in favor of this view : 

(a) They give oxidase reaction. 

(b) They tend to increase in conditions 
where bone-marrow is stimulated. 

III. Xormal numbers and variations. 

6-8% when taken together (1-3% large 
mononuclears, 3-1% transitionalsj. 
Increase : 

In any case of myeloid stimulation, 
(Drug intoxication, especially salvarsan.) 
Three common views as to origin : 

1. Young lymphocytes. 

2. Endothelial cells. 

3. Myeloid. 

Function — little known; increased espe- 
cially in malaria. 
Abnormal White Blood Cells. (Xever in peripheral 
blood normally.) 



214 

A. Myeloblast — parent cell of all myeloid white 
blood cells. 

Size — 12-15 microns (great variation). 

Nucleus — large, lepto chromatic. 

Stain — cytoplasm stains a purple or light 
blue; nucleus stains a lighter blue. 

Protoplasm — plentiful, often thicker on one 
side of the cell than on the other side. 

Nucleoli — numerous (3-6), closely grouped, 
easily seen, but with no clearly defined nucleo- 
lar membrane. 

Granules — non-granular cell. 

Function — gives rise to other cells. 
Diiferentiation from lymphocytes : 

1. Usually larger in size. 

2. Nucleus doesn't stain as intense a blue, i. e., 
not picnotic. 

3. Protoplasm has a reddish tinge. Lj'mpho- 
cyte, greenish with clear perinuclear zone. 

4. Has three or more nucleoli. 

5. They give oxidas!e reaction. 

(). Where myeloblasts occur, various stages to 
myelocytes usually occur also. 



^ 



B. Myelocytes — three varieties. 

a. Neutrophilic myelocyte. 

b. Basophilic myelocyte. 

c. Eosinophilic myelocyte. 

Myelocytes are the same in size, shape and 
staining reactions as the myeloblasts. They 
differ in having distinct types of granulation. 
In neutrophilic and eosinophilic myeloc^'tes^ 



215 
the youth of the cell is shown by the differ- 
euces ill size and staining reaction. 




Occurrence of Myelocytes : 

1. Never normally. 

2. Myeloid leukemia (more acute the disease, 
more numerous the myeloblasts — showing 
higher origin). 

3. Marked hj^per-leukocytosis. 

4. Bone marrow exhaustion (long standing 
anaemias). 

5. Pseudo-leukaemia of infants. 

In general, when there is a marked num- 
ber of myelocytes it may be regarded as mye- 
loid leukaemia until proved to the contrary. 
Differentiated from : 

1. L^anphocytes : 

a. Character of nuclei. 

b. Perinuclear zone (clear zone in lympho- 
cyte). 

c. Number of nucleoli. 

d. Protoi^lasm. 

2. Large Mononuclears and Transitionals. 

a. Protoplasm more reticulated in L. M. 

b. Difference in granulation. (Granules of 
L. M. do not stain with Ehrlich.) 

Function — give rise to P. M. N., P. M. E. 
and P. M. B. in the peripheral blood. 

Promyelocytes are the intermediate cells be- 
tween the myeloblast and the myelocytes. 

Metamyelocytes are intermediate cells be- 



216 

tween the myelocytes and the normal P. M. N., 
P. M. E. and P. M. B. 
C. Abnormal myeloblasts — ''irritation cells of 
Turk." 

Size — large. 

Protoplasm — \evj basic. 3-10 yacuoles. 

3-5 nucleoli. 

Multilobular nucleus. 

Stain as do myeloblasts. 

]Sion-gTanular. 

Xo perinuclear zone. 

Xo characteristic presence or absence in any 
disease. 

Genesis of AY. B. C. 



Afye^ohZa^si^ 





Af'C-r-a :^ye /^•^•^•z ^i 



_Zr>^;,rz4r/«-<5r^ y^r-^^Z, 


















Other Abnormal Cells. 

1. Pathological lymphocyte — Riecler cells. 

2. Irritation forms — Turk cells, 

Pathological mononuclears. 

3. Plasma cells. 

4. Megakaryocytes. 



217 

Pathological lympliocytes — Eiecler cells. 

Large cells — often resemble myeloblasts. 

Entirely different from normally occnrriug 
hTnphocytes. 

Xncleus trachychromatic. 
Characteristics are : 

Abnormal lobing, nuclei as a rule stain 
poorly. 

Usually lymphocytic in type with Giemsa 
and Romanowsky. 

Protoplasm sparse and may seem absent; 
often broad azure granules and shows basic 
staining. Well defined, clear perinuclear zone 
and vacuoles. Reticulated. 

Cells give no guiac, nor indol blue reaction. 

One sees numerous transitional forms to 
normal, large and small lymphocytes^, but 
never to transitionals or large mononuclears. 

Occurrence — Acute leukemia and in the 
aleukemic state. Chronic leukemia, uncom- 
mon. Basedows ; occasionally in infectious 
diseases. 

Cells are easily broken up and, therefore, 
give rise to smudges. 

Irritation forms of Turk — Pathological mye- 
loblasts. (See above.) 

Large cells with round or oval nucleus, 
leptochromatic. 

Protoplasm abundant, basic, vacuolated 
(3-8-10, more than lymj)hocyte). 

Azure granules absent, protoplasm is red- 
brown with Ehrlich. 

No perinuclear zone. 

Indol blue reaction etc. 

Occurrence : Leucocytosis : fat necrosis. 
Acute myeloid leukemia. Lead poisoning — • 
not uncommon. Xever normallv. 



218 

?). Plasma cells. 

Occur in the blood very rarely, best dis- 
missed. 

Cells of lymphatic nature, large, eccentric 
nuclei with spoke-like structure and unusual- 
ly thick strands of chromatin. 

Protoplasm intensely basic and perinuclear 
zone marked. 
4. Megakaryocyte. 

Giant cell of the blood. 
Occur very seldom : large, bizzare-shaped 
nucleus, many nucleoli. 

Inner granular cell surrounding nucleus 
and outer basic zone. 

Bone marrow — m^^eloblast — megakaryo- 
cyte. 

Give rise to platelets. 
Evidences of age and youth in W. B. C. 
1. Evidence of youth is basic reticulated proto- 
plasm. (Seen best in myeloblasts, also in 
young P. M. N.'s.) 
'1. Presence of basophilic granules along with 
neutro or eosinophilic. All granules in early 
age possess a basic component. Ehrlich first 
called attention to this. (Larger the granules 
the younger the cell.) 
.3. Young cells usually have easily demonstrable 
nucleoli. They are often not visible with ordi- 
nary staining methods. (The younger rhe cell 
the easier it is to see nucleoli.) 

4. Young cells have characteristic round nuclei. 
(They are seen in myeloblasts and young lym- 
phocytes.) 

Oval nucleus — sign i^ell is older. 

Nuclear polymorphism is sure evidence of age. 

Open network in young cells. 



219 

o. The size of the cell is not necessarily an evi- 
dence of youth, though it is often so. 
6. Staining characteristics of the nucleus : 
Young cells have paler nucleif?). 
Young cells show network structure. 
Older cells show picnosis. 
Review of nuiin differences between myeloid and 
lymphoid cells : 

(a) Histological differences. 

(b) Morphological differences. 

(c) Chemical differences. 

(d) Biological differences. 

(e) Embryological differences. 

(f) Comparative anatomy differences. 

(g) Pathological differences. 

Remarks on Xomenclature — confusing terms. 

(a) Acidophile cells — eosinophiles. 

(b) Basophile cells — two varieties meant: 

1. Cells with basic protoplasm. 

2. Cells with basic granulations : a. old, b. 
new. 

(c) Hematoblast has two meanings: 

1. Blood platelet — Hayem. 

2. Megakaryocytes. 

( d ) Leukoblast ( Pappenheim ) — Promyelocyte, 

(e) Lymphoblast is used in two ways: 

1. Parent cells of lymphocyte. 

2. Large cells of germ centers. 

(f ) Lymphoid cells — a bad term. 

(g) Marrow cells— white bone marrow cells, gran- 
ular and non-granular. 

(h) Mast cells — basophilic leucocytes. 
(i) Myeloblasts referred to as: 

1. Lymphoid bone marrow cells. 

2. Bone marrow lyuiphocytes. 
(j) Rieder cells. • 

Remarks on tlie varieties of bone marrow. 



220 
Occurrence of each : ~i 

(a) Erythroblastic marrow — red. 

(b) Myelocytic marrow — grayish. 
(cj Myeloblastic marrow — gray. 

(d) LjTiiphatic marrow — grayish. 

(e) Aplastic or regenerative — yellow. i 
Kemarks on differential blood counts. 

Normal cells : 

P. M. N. 

P. M. B. • > 

P. M. E. 

Lymphocytes — small and large (small mono- 
nuclears). 

Transitionals. 

Large mononuclears. 
Pathological cells : 

Myelocytes — neutrophilic. 

Myelocytes — basophilic. 

^klyelocytes — eosinojDhilic. 

Pathological Ijanphocytes. 

Myeloblasts. 

Always note abnormal red blood cells and plate- 
lets. 

Possible changes in W. B. C. count : 

1. Unchanged, 

2. Decreased — leucopaenia. 

3. Increased — leucocytosis. 

Leucocytosis mild — mild infection — good resist- 
ance. 

Leucocytosis moderate — severe infection — poor re- 
sistance. 

Leucocytosis high — severe infection — good resist- 
ance. 

Leucocytosis low — severe infection — poor resist- 
ance. 



221 
Occurrence of Leiicoc3'tosi.s : 

1. Physiological. 

(a) New-born (12 to 20,000). 

(b) Digestion. 

(c) Pregnancy. 

(d) Cold and exercise. 

2, Pathological. 

(a) Post hemorrhagic. 

(b) Inflammatory. 

(c) Toxic — acidosis, gout, lead poisoning. 

(d) Many inectious diseases, 
eucopenia occurs in: 

(a) Emaciation. 

(b) Infectious diseases, malaria, influenza,, 
measles, pertussis, typhoid, 

(c) Chronic lues, tuberculosis. 
Differential blood pictures : 

1. W. B. C. increased — formula normal or in- 
creased in any cell type; 

(a) Leucocytosis with normal balance — in in- 
fectious diseases not associated with pus 
(mumps). 

(b) Leucocytosis Avith P. M. X. increase — pus. 

(c) Leucocytosis with P. M. E. increase — para- 
sitic, skin infections, anaphylactic. 

(d) Leucocytosis with mononuclear increase — 
infection of lymphatic system. 

2. W. B. C. Normal — with cells of one or other 
variety increased. 

(a) Leucocytosis — poor resistance. 

(b) P. M. E.— parasites. 

(c) Lymphocytes — in children, lues., tbc, etc. 

3. W. B. C. Decreased — formula relatively nor- 
mal, one or another cell increased. 

(a) Leucopaenia with normal P. M. N. count 
in overwhelming infection (high % P. 
M. N.) 



222 

(b) Increased V. M. E.— particularly in severe 

anaemias starting to improve. 
( c ) Lymphocytosis — pertussis, tvplioid, nui- 

laria, tbc"., P. A. 
((1) Large Mononuclears and Transitionals — 
typhoid and leukaemias. 
.\ Consideration of Blood Platelets. 
Blood platelets originate from Megakaryocytes. 
Tliey disintegrate rapidly. -In stained specimens 
there is a mend)rane with purple staining chromatin 
inside the cell. They have amoeboid activity, which 
accounts for their bizai-re shapes. 

Function of platelets : To form thrond)in and neu- 
tralize antithrombin. Tlie}^ are also thought to play 
same role in immunity. 
They can be studied: 
1. In good smears, 

'2. Indirectly — drop into normal metaphosphate 
and count platelets and R. B. C. Calculate 
number of platelets by proportion. 
3. Aqueous solution of cresyl violet 1-800. 
Aqueous solution of KCN 1-UOO. 
Mix before use in proportion of two parts of 
the first to three of second. Keep iced before 
hand. AYait from 15 to 20 minutes, and then 
platelets are plainh^ seen. 

Normal count is 250.000 to 300,000. 

Increased in : 
Toxic or infectious states if nuld. Stronger 
ones decrease them. (Increase is good omen.) 
Clironic diseases. 

In secondary anaemia unless there is bone 
niarrow aplasia. 
In myeloid leukemia. 
Critically after hemorrhage. 
After splenectomy^ in two to four days. 



223 
Decreased in : 
OverwJielming infection. 
Lymphoid leukamia. 
Pernicions anaemia. 
True aplastic anaemias. 
Purpura hemorrhagica. 
Hemophilia. 
After benzol. 

Considerable emphasis laid upon the studies 
of Duke and Minot. 
The Anaemias or Er^^thropaenias. 

1. General definition of anaemias and other terms, 
Oligaemia — oligocythaemia . 
Oligochromaemia — hydraemia. 

2. General symptomatology of anaemic states : 
(a) Color — is only judged in terms of mucus 

membranes. The color of the skin in S. A. 
tends to be doughy white, while in P. A.. 
with the same or lower per cent of Hb, the 
skin tends to be a lemon color. 
(bj Eyes — eye grounds with loss of vision and 
floating spots from hemorrhages in the 
retina. 

(c) Dyspnoea — weakness. 

(d) Oastro-intestinal symptoms — lo^s of appe- 
tite, 801*6 tongue or mouth, dermatitis ffom 
underlying anaemia or achylia. (Flatu- 
lence — especially in people over 3o.) Jaun- 
dice. 

(e) Oedema — swelling in feet and ankles. 
Swelling of feet and ankles not ahvays 
orthostatic. 

(f ) Neurasthenia. . 

3. Classifications of anaemias. 
(a) Etiological: 

Defective forniation — hypoplastic. 
Increased destruction — consumptive. 



(I)) Haeiiiatological: 

Chlorotic (low index ». 
Pernicious (high index). 
(ci Histological: 

l*riniary myelogenous — primary — embry- 
onic erythropoesis. 
Sc^condary myelogenous — secondary — post 
embryonic erythropoesis. 
( d I Clinical grouping : - 

Primary. Secondary. 

Chlorosis Acute hemorrhagic 

I'ernicious Chronic hemorrhagic 

Primary aplasia Chronic secondary 

Leukanaemia Secondary aplastic 

Leukaemia Hemolytic 

Anaemias of children. 
Klood picture in stages of secondary anaemia. 

1. Oligaemia Avithout anaemia — proportional de- 
crease (C. I. normal) — inhibition on the part 
of the bone marroAv. 

2. Hydraemia — AA'ith thirst — reduced cell count 
A\dth low C. I. characteristic. 

3. LoAA' C. I. — regeneration — metaplasia — imma- 
ture cells---normoblasts, macrocytes, intense 

marrow actiAdty. Megaloblasts occur infre- 
quently in true secondary anaemia. Ked cell 
formation exceeds hemoglobin. 

4^. Normal — formation of red blood cells stops — 
restitution of Hb. Hemoglobin may exceed red 
cell formation — index plus. 

Causes of S. A. 

1. Loss of blood. 

2. Infections — chronic. 

3. Malignant tumors. 

4. Chemical — paroxysmal hemoglobinuria. 

5. Parasites. 

6. Secondary purpura. 



229 

Leucocytes — no characteristic clianges, usually 
normal and normal differential. 

Platelets — constantly increased. 

Treatment : Much iron given. (Some anaemic peo- 
ple called chlorotic, but tliis is really a misnomer, j 

Pernicious Anaemia. 

There is a limitation of the term. Pernicious 
anaemia is best given up and the term chronic hem- 
lytic anaemia used or "Addison-Biermer type of 
anaemia." Other terms are Addison anaemia, Addi- 
son-Ehrlich and Biermer-Elirlich anaemia. Biermer 
gave the first classical description in 1868. Ehrlich 
showed that there is a reversion to embryological 
type. Pernicious anaemia is not a disease entity, 
but a similar picture can be caused by conditions 
not necessarily fatal. The typical case shows a 
typical blood picture, certain symptoms, etc., with 
a chronic, progressive, hemolytic anaemia of un- 
known cause. The group is activity increasing. In 
horses an analagous anaemia of infectious origin 
occurs which can be transmitted. 

Conditions which require exclusion : 

1. Worms — mostly of the flat- worm variety. 
(Fatty acids given off by the segments can 
cause anaemia in other animals.) 

2. Malignant tumors. 

3. Syphilis (clears up under therapy). 

4. Severe chronic types of malaria. 

5. Toxin given off' during puerperium. 

6. Toxins due to metals — lead, etc. 

The cause of the disease is unknown, but there 
are various theories : 

1. Toxins arising from gastrointestinal tract. This 
is a favorite theory, emphasized by Sir William 
Hunter. Bad teeth and mouths responsible. 

2. Achylia gastrica — not true gastric atrophy. 

3. Primary cause in spleen. (Comparatively re- 



226 
Enmiiercition of the distinguishing features : 

1. Usually the histoiy is helpful. 

Never omit careful gastric, stool, sputum, 
urine examinations for occult blood. 

2. K. B. C. not usually so low as in P. A. 
Stained smears show characteristic degree 
of pallor, shadows of cells. (Bone marrow 
may throw out deej) staining cells.) 

Smaller K. B. C. — degree of anisocytosis 
and poikilocytosis less. 

Normoblasts rather than megaloblasts 
(therefore C. I. very generally definiteh^ be- 
low 1 — watch C. I. carefully). 

3. Platelets increased, or, at least, more than 
in P. A. 

4. ^Y. B. ,C. either slightly increased (early 
stages), normal, or decreased (later stages), 
but not as much as in P. A. and less reduc- 
tion of P. M. X. Seems a sliding down of 
whole picture rather than repression of 
leucocytes. 

ril. Secondary Aplastic Group — Aregenerative 
Anaemias. 

Enumeration of the causes — bone marrow not 
changed to red. 

1. Drugs, benzol, lead, arsenic, etc. 

2. Long hemorrhagic state. 

3. Severe septic conditions. 

Chief interest resides in the ability to diag- 
nose cases from aplastic forms of P. A. 

History very important. 
Blood picture, as a rule, shows: 

1 . Parallel reduction of E. B. C. and hemo- 
globin. 

2. Color index nearly normal (perhaps a little 
under j . 



227 

0. Anisocytosis and poikilocytosis usually 
slight. 

4. Absence of myeloid elements with leuko- 
paenia. 

5. Few or no nucleated K. B. C. Platelets gone. 
TV. Hemolytic Anaemias or Hemolytic Icterus. 

Described by French : congenital family dis- 
ease. Clinically a disease often present from 
early life with periods of fever, icteric tint, 
weakness, anaemia, urobilinuria and splenome- 
galy. 

A. Chronic icterus. 

1. Congenital. 

2. Acquired. 

B. Acute forms — new-born, infections, hepatic 
diseases.' 

Blood findings : 

1. Anaemia is variable; usually moderate 
(rarely below 2,500,000). 

2. X^sually many regenerative evidences, espe- 
cially basophilic cells. 

3. Large numbers of vitally staining K. B. C. 

4. C. I. around normal — sometimes greater 
thanl. . 

5. Characteristic microcytosis. 

6. Punctate basophilia — uncommon. 

7. Usually W. B. C. slightly plus. 

8. Platelets increased. 

9. Diminished resistance of K. B. C. 
Good x3rognosis. 

Secondary anaemia occurs often in people 
who live under poor hygienic conditions. 
Marked improvement with fresh air, good food, 
etc. 

Secondary anaemia develops rapidly in pa- 
tients stricken with acute infections. (Typhoid, 
l)neumonia, rheumatic fever, etc.j 



232 

I. Patient's history — can't pin onset to any defi 
nite time. 

'2. Physical examination. 

(a) Characteristically well nourished. 

(b) Lemon or straw color. 

(c) Complete achylia gastrica. 

( d ) Urobilinnria — constant. 

(e) Frequent retinal hemorrhages. 
3. Blood side. 

(a) R. B. C. reduction out of proportion to 
hemoglobin. 

(b) Anisocytosis and poikilocytosis, Ayith prev- 
alence of macrocytes. 

(c) High C. T. 

(d) Leukopaenia. 

(e) Diminution in blood pressure. 
Differential diagnosis : 

T. Anaemias of Childhood. 

1. Occur in young children. 

1\ Tendency to revert to embryological blood 
picture ( megaloblasts predominate ) . 

8. R. B. C. count reduced markedly and hemo- 
globin reduced i)roportionately. Low C. L 
Poililocytosis and anisocytosis marked. 
Polychromatic cells. 

4. W. B. C. 
Leucocytosis (20,000). 
Predominant cell — ^P. M. X. 
Some abnormal W. B. C.'s. 

5. Platelets about normal. 
Clinically : 

No characteristic lemon color to the skin- 
rather pasty. 
No urobilinnria. 
Rapid febrile course. 
Enlargement of liver and spleen. 

II. Aleukemic states of leukemia. 



225 
7. Cachexia with poor hygiene. 

I. Acute Hemorrhagic Anaemias. 
Enumeration of common causes. 
( a ) Severe hemorrhage. 

(a» (t. I. tract. (Eoophageal, pharyngeal — 
acute haem. — gastric ulcer. I 

(c) Kespiratory (tbc, erosions of aneurisms, 
parasitic ) . 

(d) (t. F. (renal epistaxis, renal neoplasm t b, 
bladder conditions). 

Regeneration quickest in men ( 25 to 40 ) . 
Slowest in children. Minimum C. I. occurs 
around ninth day: nucleated K. B. C. 7-8 days. 

Rapidity of regeneration after hemorrhage. 

Blood loss — 4.5% body weight — entirely re- 
formed within 8 days. 

Blood loss :*% body weight — within 8 days. 

II. Chronic Hemorrhagic Anaemia. 
Succession of hemorrhages without recovery 

between. 
Enumeration of common causes : 
( a I Mild hemoptysis. 

(b) Tbc. 

(c) Hemorrhoids. 

(d) Extreme and too frequent menstruation. 

(e) Xose irritation, etc. 
Blood findings : 

R. B. C. down to 1,000,000, usually small and 
pale. 

Nucleated R. B. C. not abundant. 

Platelets increased or not. 

Leukopaenia common. 

Picture varies Avith duration of anaemia; 
long-continued insults, bone marrow exhaus- 
tion and aregeneration becomes poor. 

Ultimately blood picture may resemble P. A. 



230 

cent theory.) There is said to be much fatty 
acid in the circuhition, which disappears after 
spleenectomy. 

No theory holds good for all anaemias. It is a 
toxic anaemia, probably the expression of absorption 
or the action of one or several toxins of varied 
origin (probably related to the fatty acid or lipoid 
group), causing morphological and functional 
changes in the bone marrow and constant reversion 
to embryonic type. 

The disease occurs in people of middle years 
(35-40), but can occur in people much older (in the 
70s) and has been known in children. It is no re- 
spector of persons, occurring among the rich as well 
as the poor, but probably more in the male sex. 
It sometimes has a family tendency. 

Clinical symptoms and picture. 

1 . Gastro-intestinal symptoms : 

(a) Sore tongue. 

(b) Active stomatitis. 

(c) Achlorhydria. 

(d) Loss of appetite, indigestion, weight in 
■ stomach after eating, 

(e) Frequently diarrhea. 

2. Cardio — respiratory system. 

(a) Dyspnoea. 

(b) Swelling of ankles. 

3. Nervous system. 

(a) Numbness or tingling of hands or feet. 
(Exclude syphilis.) 

(b) Depressed, easily fatigued. 

(c) Changes in the cord (unsteadiness of gait, 
cushion under feet, etc.) 

4. Urine. 

(a) Slight albuminuria. 

(b) Urobilinuria, prolonged and persistent. 

5. Slight irregular fever. 



231 



C). Other findings 



(a) Yellow tint to the skin and conjunctiva. 

(b) Petechiae, not characteristic. 

(c) Liver and spleen may be slightly enlarged. 

(d) Good nutrition. 

(e) Patients don't come to doctor till blood is 
way down. 

Blood Picture. 

Total volume reduced. Hydraemia, pale, coagula- 
tion often delayed. Sj)reads quickly, corpuscles seem 
to settle quickly. Clot small (Brilliant yellowish 
green tint to serum-urobilin ) . 

Formed elements. 

Red blood cells reduced to 1,500,000. (As low as 
113,000, with recovery.) Striking anisocytosis — gen- 
eral tendency to predominance of deeply staining 
macrocytes. High percentage of poikilocytes. Mod- 
erate basophilia. Nucleated reds in small numbers, 
megaloblasts predominating. Platelets decreased. 
Hemoglobin per cell high. C. I. .95 to 1.5. W. B. C. 
decreased per cent of P. M. X., P. M. E., P. M. B., 
L. M., and transitionals while the per cent of Lym- 
phocytes is increased. During a remission the 
eosinophilic cells are increased together with other 
cells of myeloid origin, while tlie lymphocytes fall. 

Clinical course of disease: 

The onset is usually gradual and progressive. The 
disease may last from 1 to 10 years. It is charac- 
terized by a feeling of well-being till the R. B. C. 
count drops markedly low. Wave-like remissions 
occur, which may last from 1 to 6 years. An occa- 
sional cure is reported. The end usually comes from 
an intercurrent infection or from an acute exacer- 
bation. A gradual mental stupidity and toxaemia 
comes near the end and the patients die similar to 
those with hepatic disease. 

Valuable poiijts in diagnosis and ]3rognosis. 



228 

Primary' Anaemia. An anaemia for which there 
is no ascertainable cause. 

Chlorosis. A very rare disease of unknown etiol- 
og3\ Scarcely ever found in the United States, some- 
times in Germany. Limited to female sex and usu- 
ally appears at onset of adolescence (14 to 20), but 
has been known to occur up to 35. Distinct family 
and recurrent tendency, especially if individual ever 
has anaemia. Numerous theories as to cause — "love- 
sick anaemia" — also some think due to constitu- 
tional deficiency of tlie bone marrow to synthesize 
hemoglobin. 

Xo typical ])athological lindings; 

Chlorosis is a distinct disease and anaemia is only 
a symptom of it. 

Xo actual destruction of K. B. C. 

Symptoms : Weakness, fatigue, fainting periods, 
dizziness, G. I. symptoms (perverted taste, fondness 
for pickles, etc. ) , menstrual function is disturbed. 

Chlorosis is possibly an internal secretion dis- 
turbance. 

Hysteria is common. 

Characteristic green ( sea-sick green i color to pa- 
tient's face. (It was once thought to be du to i^oor 
nutrition, but this theory is probably wrong.) 

Blood findings: R. B. C. decreased; however, this 
decrease is relatively slight and wholly out of pro- 
portion with the great decrease in Hb. (Here Dr. 
Thayer gives the R. B. C. as 4,000,000 and Hb. as 
42%.) This consequently results in a phenomenally 
low C. I. (beloAv 0.5). Pale R. B. C. Anisocytosis 
and poikilocytosis slight and often absent. If there 
is anisocytosis, the common cells are microcytes. 
Xucleated R. B. C. are few, and those that occur 
are of the late normoblastic type. The occurrence 
of a megaloblast is extremely rare. 



237 

ble, not caseous, and often have multiple hem- 
oiTliages in the acute forms. They rarely give rise 
to obstruction, as there is no tissue reaction around 
them. 

Spleen: The form is smooth, with the notch pre- 
served. Rarely reaches to the umbilicus, and rarely 
produces abdominal discomfort. 

Bones : Pain present in the late stages. 

Skin : There may be present multiple lymphomata, 
especially on the face and upper throat. They are 
small, painless, and never break down. Lympho- 
dermia perniciosa, a disease with great itching, 
may be the first symptom. 

Mouth: Affections of the mouth are relatively un- 
common. Mikulicz's disease is symmetrical tumor 
formation of lacrimal and salivary glands. 

Heart and lungs : Negative. 

Urine: Bence- Jones proteinuria and uria acid 
notable. 

Temperature: Fever not predominant. 

Duration: 3-5 years before use of X-ray. There 
is a tendency to intercurrent infections, which oblit- 
erate picture. 

Blood findings : 

Gross appearance — creamy, almost ptirulent. 

E. B. C. normal or slightly reduced. 

C. I. about normal. 

Slight anisocytosis and poikilosytosis with poly- 
chromasia — normoblasts. 

W. B. C. leucocytosis may reach 000,000. Lym- 
phocytes, 90-96%. 

Reider cells may be present. Azure granules are 
absent. Otherwise cells look like normal, except 
that they stain with a "Heller Farburg." 

The nucleus is less picnotic, therefore the nucleoli 
can be seen. 

Many of the cells crush indicating youth. The 



234 

IJemoglobiii low. C. I. .0 to .7. 
Platelets gone. 

Pronounced leukopaenia (1,200 to 2,000). 
At autopsy one finds metaplasia of bone 

marrow. Xo islands of actively func 

tioning red or white cells. 
(Musser) : 
1. Coagulation time distinctly delayed. 

2. Xo reticulated blood cells ever found. 

3. Minimal resistance unchanged. 
Maximal resistance increased. 

Etiological factors in aplastic anaemia : 
Three groups : 

1. So-called aplastic anaemia from chronic 
repeated hemorrhages, characterized chief- 
ly by history. 

2. Destructive property of some toxin, hemo 
lytic in origin. They include all the 
chronic hemolytic anaemias. 

The clinical history is very important. 

3. Aplastic P. A. In the aplastic stages of 
P. A. there is a constantly dropping W. B. 
C. count and no evidences of E. B. C. re- 
generation. 

Xaegeli says a better name for aplastic anae- 
mia is aregenerative anaemia. 
Imi^ortant points in all cases : 

1. Clinical history. 

2. Barely reduction of B. B. C. is as great 
as in P. A. 

3. Age — usually under 30 or over 60. 
V. Carcinoma of the stomach. 

Possible existence of pain. 

Patient's historv' — same general symptoms, 
but usually loss of weight. 

G. I. findings may or may not have free 
HCl. (Pvloric end do not.) , 



235 

. Occult blood apt to be absent in P. A. 
Stomach Inperniotile in P. A. 
Blood : 

Allow to clot — likely to look normal in car- 
cinoma. 

In P. A. serum lias high color, but not same 
proportion between clot and serum. 
R. B. C. rarely below 2,000,000. 
Poikilocytosis and anisocytosis less marked 
as a rule. 

C. I. hovers around 1, varies more than in 
P. A. 

Platelets usually plentiful. 
W. B. C. usually normal or above. P. M. N. 
increase. 

X-raj^ does not always show distinction. 
Leukemia s. 

A leukemia is a disease characterized by an in- 
crease in the Avhite cells of the blood usually abnor- 
mal, and by a general hyperplasia of the leukopoie- 
tic organs of the body. The blood condition is a 
symptom of this hyperplasia. There may be a digres- 
sion between hyperplasia and leucocytosis. Leuke- 
mias may have a count as low as 50,000, and a leuco- 
cytosis may reach 100,000. Leukemias were recog- 
nized by Virchow in 1845 and clinically in 1850. 
The classification at that time was : 

1. Splenic, 2. Lymphatic; depending upon which 
was enlarged. 

There are no true transitional stages between tlie 
lymphatic and the myeloid which speaks for the 
dual origin of these cells. In lymphoid leukemia 
the bone marrow^ is involved very late. 

Possible sources of origin : 

1. Parasitic — amoeba. 

2. Cancer. 



240 

lymph glands, exophthalmos, periosteal' infil- 
trations, etc. 
31yeloses. 

^[yeloid lenkemias are general hyperplasia of the 
myeloid tissue . They have the same general group- 
ing as the lymphatic lenkemias. 

1. Chronic myeloid leukemia. 

2. Acute myeloid leukemia. 

:>. Chloromyelosis (myeloid chloroleukemia ) . 

4. Aleukemic myelosis. 
1. Chronic Myeloid Leukemia. 

Occurs chiefly in people in middle lite, more in 
men than in women, rarely in children. It is char- 
acterized by slow development with gastric symp- 
toms, weakness, poor sleep, often marked sweating. 
(Often tuberculosis is suspected.) 

Special symptomatology. 

( a I Enormous enlargement of spleen, with smooth 
surface, hard, and notch preserved. Usually 
sensitive. 

(b) Liver enlarged, smooth, hard, keeps normal 
shape. Rarely jaundice. 

(c) Lymph glands not enlarged and inconspicu- 
ous. 

(d) Bones frequently tender and patient often 
has bone aches. 

(e) Ascites. 

(f) No enlargement of tonsils (except late). 

(g) Irregular fever. 

(h) Hemorrhagic diathesis rare, however, ten- 
dency to skin eruptions. 
(i) Priapism. 
(j) Amenorrhea. 
Blood findings : 
Gross color unchanged at first. 
Blood thick, coagulation time increased. Oxidase 
reaction marked. 



233 

Remission stage — decrease in AY. B. C. 

Usually well marked anaemia, but never so 
severe as P. A. 

Characteristics of Secondary Anaemia. C. I. 
low, cells pale, if nucleated tend to be nor- 
moblasts. Nucleated forms tend to be pres- 
ent more than they ever are in P. A. 

Differential count shows greater peculiarities 
than P. A. 

III. Leukanaemia. 

Larger number of megaloblasts. 

Severe anaemia with leucocytosis. 

Probably atypical forms of Von Jaksch's 

(may occur in older people). 
Rapid course — usually die within 2 months. 

IV. Aplastic anaemias. 

An anaemia different from any pernicious or 
secondary anaemia, characterized by retro- 
gressive changes in the bone marrow. ( At 
autopsy one finds all the bone marrow re- 
placed by fat.) 

1. Primarily of young people. (May be seen 
from 5 to 60. ) Well under 30 as a rule. 

2. Clinical course different. Jlapid and pro- 
gressively fatal. (Two months and as low^ 
as 6 days.) 

8. From the start tendency to subcutaneous 
and mucus hemorrhages. 

4. High and persistent fever. 

5. Blood picture: 

R. B. C. — severe and intense anaemia. 

(1,000,000.) 
No poikilocytosis or anisosytosis. 
May be slight general increase in size. 
Absence of polychromasia of any type. No 

nucleated reds. 



238 

protoplasm is basic and seems almost absent in 
many. 

Blood platelets — diminisbed. 

Diagnosis — blood picture. 

Difterential diagnosis : Lympbosarcoma, tbc, and 
myeloid leukemia . 

l^rognosis : Fatal after remissions. 
-. Acute Lympliatic Leukemia. 

1. r^ever, witb prostration. 

-. (iangrene and ulcer in G. I. tract. 

^1 Hemorrbagic tendency. 

J. Rapid course of disease. Anaemia, cacbexia, 
deatb in one to tAvo montbs. (Minimum one 
week.) 

5. More acutely fatal and common in cbildren. 

(5. Tbere is higb irregular fever. 

7. Progressive splenic and lympbatic enlargement. 

Diagnosis : Ulcerative tonsilitis and stomatitis. 
Prodromal period, witb occasional mild attacks of 
fever and general malaise, followed in a few weeks 
witb cervical glandular enlargement, tben witb a 
flare up and extensive bemorrbage and tbe picture 
above given. 

Blood picture — abounds in lympboid cells. 

Otber groups : 

1. Like acute rbeumatic fever — polyarticular, usu- 
ally painless involvement. 

2. Like typboid — diarrbea and abdominal pain. 

3. Like pleurisy. 

4. Like meningitis. 

3. Cblorlympbadenoses. In tbis condition tbere are 
tumors in various parts of tbe body witb cbar- 
acteristic greenisb tinge. Tbey are divided into 
groups according to location. 

1. Tumors in or on tbe skull. Symptoms — 
exopbtbalmos, generally symmetrical, witb 
swelling of tbe occipital and temporal regions. 



239 

2. Subperiosteal infiltration of the spinal column, 
ribs and pelvic bones. 

3. Lymphatic leukemia Avith tumors, but only at 
autopsy does the green color of the tumors be- 
come apparent. 

In all the cases the blood picture is that of chronic 
and acute lymphatic leukemia, and the tumors show 
chronicity, which runs with leukemia. Most cases 
are rapidly fatal and show no remissions. Over 
50 per cent of the cases are in children. 
4. Aleukemic Lymphadenoses. 

This is a leukemic state with low AY. B. C. count. 
Clinical differences— lymph glands not as swollen, 
course of disease is quite chronic and may develop 
into chronic lymphatic leukemia. 

Blood picture is practically the same, qualitative- 
ly, as lymphatic leukemia, but absolute numbers 
are lower. 

Naegeli groups into six types: 

I. General lymphatic hyperplasia (aleukemic 

blood picture). 
II. Lymph hyperplasia more localized^glands 
adhere to one another and the un<lerlying 
tissues so that the diagnosis of h^mphosar- 
coma is sometimes made. 
III. Very large splenic tumor with oniy slight 
lymphatic hyperplasia. Spleen shows uni- 
form enlargement and keeps normal form. 
IV. Localized lymphatic infiltrations in pharynx, 
larynx, eyelids and cheeks. Spleen may be 
large or small. 
V. Slight anaemia and low fever, aleukemic 
state. Suddenly acute leukemia, severe hem- 
orrhagic diathesis and death in a few hours. 
Actual bleeding from skin. 
Vl. Chloroma in skull with aleukemic blood 
picture. Enlargement of spleen, liver and 



236 

3. luleclious — present view. Facts wliicli suj)- 
port view: 

(a) StoruiT, rapidly progressive, febrile con- 
dition. 

lb) Apparently follows septic conditions. 

(c) Apparently contageous in a few cases at 
least. Similar condition can be trans- 
mitted in animals. 

Lymphadenoses. 

These are conditions associated with lymphatic 
hyperplasia and with characteristic blood picture. 
Kinds : 

1, Chronic lymphatic lenkemia. 

2. Acute lynix)hatic leukemia. 
8. Aleukemic lymphadenoses. 

4. Chlorlymphadenoses. 

1. Chronic Lymphatic Leukemia. 

Begins in childhood or in young adults with slow 
onset and probably aleukemic states, Avith only 
qualitative blood picture changes during period of 
hyperplasia. Sexes evenly distributed. 

Symptoms : 

1. Marked enlargement of tonsils. 

2. General symmetrical enlargement in neck and 
axilla. 

3. Splenic enlargement with perisplenitis. 

4. Hemorrhagic diathesis (bleeding from any 
mucus membrane). 

5. Severe headache and visual disturbances. 

G. Usually anaemic symptoms (languor, slight 
loss of weight, etc.). 

7. Stitch in side and signs of pleurisy. 

Glands : There are generally enlargements some- 
where, sometimes ahead of the other symptoms. 
Sometimes only the retroperitoneal glands are in- 
volved. They are usually soft, isolated, not adher- 
ent, rarely matted together. They are grayish, fria- 



241 

E. B. r. :],50(),000 to 4,000,000. rolychromasia, 
large numbers of nucleated reds. Hb. reduced pro- 
portionately — therefore about normal C. I. 

Platelets markedly increased. 

W. B. C. 

Increased and may go up to 1,000,000. 

Large myelocytes abundant. Larger types pre- 
dominate with basic protoplasm, irregular in size 
and staining reactions. Nuclei show a fine network 
structure. Some myeloblasts. Typical P. M. N. is 
]n'edoniinating celL Eosinophiles increased in abso- 
lute count. Mast cells in no other cases seen so 
frequently. L. M. and Transitionals increased in 
actual numbers. Lymphocytes only in small num- 
bers (absolute count little changed!. Frequently 
find true megakaryocytes, but so fragile as to be 
only recognized by the nucleus. 

There are three changes of interest: 

1. Changes under X-ray and arsenic treatment. 
Cell count may drop to normal or may be same 
general count, with immature cells almost dis- 
appearing. 

2. Changes during infectious diseases — may loose 
all abnormal cells. 

3. Appearance of myeloblasts. Increase markedly 
as disease grows worse. Increased enormously 
in cases treated by X-ray and influenced un- 
favorably. In agonal stage may rise to 20-50%. 

Prognosis. 

There are stages of remission. An apparently 
slight case, perhaps lasting for years, may suddenly 
become acute, and some slight cause may bring about 
a change for the worse. Etiology unknown. 

Treatment : 

Arsenic. 

Benzol — great care should be exercised. Give small 
doses in a bland oil and stop when the count reaches 



242 

20,000 to 30,000. Wait till the count stops falling 
before giving again. 

X-ray and radium — in vogue. 

2. Acute M} eloid Leukemia. 

Kuns a course like acute lymphatic leukemia. 
Has a clinical picture of lymphatic. Distinguished 
only by blood picture. The more acute the disease 
the less typical the characteristics. 

The course of the disease is steadily progressive 
and fatal. 

3. and 4. Same thing is true as in other tAvo groups. 
It is to be remembered that any leukemia may un- 
dergo an aleukemic stage either normally or in- 
duced. 

Distinguish chronic myeloid leukemia from : 

1. Hyperleucocytosis due to infection — u^r./Zy in 
children. 

2. Severe anaemias may show high leuc \ytosis — 
rarely hyperleucocytosis. 

3. Metastasis of malignant tumors in bone mar- 
row. Picture more distorted. 

Blood findings in infectious diseases : 

1. Leucocj^tosis with absence of eosinophiles 
points to pyogenic infection, the so-called "sep- 
tic factor." The reappearance of eosinophiles is 

a favorable sign. 

2. Lymphocytosis occurs in pertussis, rickets, con- 
genital lues, tbc, measles, typhoid, influenza, 
diseases of endocrine glands. 

1. Pertussis — hyperleucocytosis, lymphocytosis, B. 
Pertussis in the sputum, R. B. C. unchanged. 
W. B. C. 22,000 to 25,000. 40 to 60% snuill 
lymphocytes. 

2. Poliomyelitis— leucocytosis, 20,000 to 50,000 
W. B. C. count with 80% P. M. N. Spinal 
ihiid with cell increase, especially small lym- 
phocytes. Absence of ^'septic factor." 



243 

?). Epidemic ineniiioitis — leucocytosis, constant 
septic factor, bacteraemia, spinal fluid shows 
specific organism with purulent fluid. K. B. C. 
unclumged, W. B. C. 12,000 to 55,000. P. M. X. 
85 to 90%. Eosinophiles diminished. Spinal 
fluid cell count shows almost exclusively pus 
cells. 

4. Malaria — leucopaenia, absence of septic factor. 
Increase in L. M. Pigmented leucocytes, and 
presence of organism. R. B. C. show anaemia 
usually, C. T. constantly low. Usually signs of 
regeneration. W. B. C. increased before par- 
oxysm, after chill rapidly developing leuco- 
paenia (2,000 to 3,000). P. M. X. decreased. 
Phagocytes of L. M., with marked amoeboid 
activity. 

Thayer's classification of blood findings in malaria : 

(a) Ordinary S. A., with abundant regeneration. 

(b) Blood picture essentially P. A. 

(c) Rapidly fulminating. 

(d) Severe, chronic, aregenerative S. A. 

5. Measles — leucopaenia, diazo reaction in urine. 
Moderate pre-emptive leucocytosis. Platelets 
decreased or absent. 

(5. Diphtheria — leucocytosis, septic factor, bacilli 
from throat, albuminuria, hig'h R. B. C. at 
first, later mild anaemia. W. B. C. 14,000 to 
:>0,000, present from early stage, and falls- 
slowly. Eosinophiles absent. P. M. X. 90%. 
Leucocytes should fall rapidly after antitoxin. 

7. Scarlet fever — leucocytosis, absence of septic 
factor^ eosinophiles increased. Diazo reaction. 
Streptococci in smears or blood cultures. . R. 
B. C. unchanged. W. B. C. show a consistent 
increase especially before the rash, normal at 
three weeks. P. M. X. 90 to 95%. Glandular 
infections (P. M. X\ go up). If leucocytes do 



244 

not respond it means severe infection. Plate- 
lets increased. Dalil's leucocytic inclnsions may 
be present. 

8. Typhoid fever — S. A., leucopaenia, increase in 
lymphocytes, blood cnlture, Widal abont tenth 
day, late diazo, no septic factor. R. B. C. 5,500,- 
000 to 4,500,000. Hb. rednced more than E. B. 
C. always. Nucleated forms rarely. W. B. C. — 
the greater the leucopaenia the more severe the 
case. P. M. X. 50%, eosinophiles absent in 
three-quarters of the disease. Mono increase. 
Favorable findings are moderate leucopaenia, 
with a return of eosinophiles in three Aveeks. 
Hemorrhage and perforation: 1. Liver dullness. 
2. W. B. C. going up from the depths. The 
count may go down. It may remain stationary 
Avith alteration in liver dullness. Hemorrhage — 
W. B. C. increase and then leucopaenia. 

9. I*neumonia — hyperleucocytosis, septic factor, 
fibrin increase. Rusty sputum, chloride reac- 
tion, pneumococci in the blood and sputum. 
R. B. C. 4,000,000. W. B. C. increased 15,000 
to 25,000. The count may diminish at first. 
P. M. N. 80 to 85%. Septic factor marked. 

Hodgkin's Disease. 

Hodgkin in 1832 described this disease Aery im- 
perfectly. 

Three theories as to origin : 

1. Cohnheim and Sternberg. A tbc. origin based 
on (a) acid fast organism, (b) Tbc. elseAA'here. 
(c) Perhaps human reaction to bo\ine. Still 
an open question. Probably coincidental rather 
than true etiological fact. 

2. True tumor. Described as pseudo-leukemia. 
Against it: (a) Histology, (b) Attempts to 
transplant a failure. 

o. True infectious granuloma. Bunting and 



245 

Yates) Diphtheroid organism and vaccine treat- 
ment. jS^ow stands as follows : 

(a) The diphtheroid can be cultivated from 
glands. 

(b) The diphtheroid can be cultivated else- 
where. 

(c) Glands in general have a normal flora 
(Bloomfield). 

Blood picture (Bunting and Yates). 

1. Kelative or complete absence of anaemia. 

•2. Kelative and positive increase in L. M. 

3. Platelets increased notoriously. 

4. Eosinophilia. 

5. Leucocytosis with P. M. X. increase. 

Many observers fail to get this picture. They 
get a slight tendency to this with many variations. 
There is no consensus of opinion as to etiology or 
blood picture. Only positive diagnosis is removal 
and examination of gland. 

Conditions with anaemia and si)lenomegaly : 

1. Banti's disease — splenic enlargement, tendenc}^ 
to hemorrhage, occurs after 25 to 30. Blood 
picture is not characteristic. 

2. Splenic anaemia — see above. 

3. Gaucher's disease — in young children, progres- 
sive splenic enlargement, anaemia, no jaundice, 
no blood destruction, no characteristic blood 
picture, familial disease. 

4. Hemolytic anaemia, acquired or inherited. True 
bone marrow dystrophy, hemolytic function of 
the spleen. Icterus, constant urobilin in acho- 
luric urine. Moderate secondary anaemia, de- 
creased resistance of R. B. C. Reticulated, 
vitally staining R. B. C. Splenectomy curative. 

5. Pernicious Anaemia with splenic enlargement. 
Paroxysmal Hemoglobinuria. 
The patient either has hemorrhage after exposure 



246 
to cold or lias secondary anaemia from unexplained 
hemorrhage. 95% have lues, and it responds to sije- 
cific therapy. The diagnosis is often made by sub- 
jecting patient to cold. 

Experiment: Use patient's serum and his washed 
corpuscles. 

Patient's serum ]3lns K. B. 0. at 37 deg. C. gives 
no hemolysis. 

Patient's serum plus R. B. C. at deg. C. gives 
no hemolysis. 

Patient's serum i^lus R. B. C. at 37 deg. C, after 
chilling at deg. C, gives hemolysis. 

Purpura and Pathological Hemorrhages. 

1. Definition of purpura: A tendency to spon- 
taneous hemorrhages developing in and be- 
neath the skin and mucus membrane in any 
part of the body. The size varies from i)in 
point to several cm. in size. 

(a) Pin point, small areas — petechiae. Chiefly 
on extremities, especially legs. 

(b) Lines or streaks — vibices. 

(c) Large areas — ecchymoses. 

(d) Extensive areas — suggilation (covering 
whole thigh, etc.). 

When recent they are usually bright red, but 
later become livid and purple. No remnants in 
time. The}^ are generally not elevated, no indura- 
tion, cannot bepressed out, differing from erythremia 
in this respect. Gangrene and ulceration common. 

They frequently come in crops, and are commonest 
on the legs and arms, and occur mostly on the ex- 
tensor surfaces. 



N 



247 
2. Occurrence: 

1. Symptomatic — secondary. 

2. Idiopathic — primary blood trouble, 

1. Symptomatic purpura. 

(a) Acute infectious diseases. It may occur 
in any infectious disease, especially where 
there is bacteraemia : 1. Typhus. 2. Small- 
pox. 3. Epidemic meningitis. 4. Endocar- 
ditis, Avhere it is especially valuable in con- 
nection with the clinical history. 

(b) Chronic malnutrition — cachexia and malig- 
nant states in general (especially of the 
bone). 

(c) Conditions associated with jaundice. Con- 
nection not known, but may be due to some 
impaired function of the liver. 

(d) Blood diseases. 

(e) Chronic nephritis — rare. 

(f) Drugs — rare. (lodin, mercury, antipyrene, 
aromatic drugs as copaiba, turpentine, etc.). 

(g) Mechanical injuries. Trauma and also due 
to the bite of parasites, etc. 

(h) Nervous forms — with hysterical seizures or 
along nerve trunks in neuritis. 
Only when all these causes are excluded can one 
go to the 'Trimary purpuras" in which the funda- 
mental cause is probably found in disturbances in 
the coagulation factors of the blood. 

2. Idiopathic Purpura. 

It was formerly thought that : 

1. Purpura simplex or Werlhoff's Disease, 

2. Purpura rheumatica or Schonlein's Disease, 

3. Henoch's Purpura, and 

4. Peliosis hemorrhagica 

were all seperate diseases, which view has been 



248 

largely abandoned. There is great confusion in the 
literature, and it is probably necessar}' to retain 
the terms until more precise knowledge is at hand 
concerning the idiopathic purpura (Morbus maculo- 
sus ) . 

Occurrence of True Purpura. 

There were 41 cases in 18,000 admissions in J. H. 
H. They occur more in the fall and winter months. 
More in males than in females — young rather than 
old. There is a clear-cut heredity role. 

Causes : 1. Vascular injury. 2. Infection with 
bacteria. 3. Pathological condition of the blood, 
vfarticularly coagulation factors. 

In any case of pathological hemorrhage certain 
blood studies are of prime importance, yiz : 

1. Estimation and enumeration of platelets. Be- 
low 60,000, bleeding apt to occur; below 20,000, 
bleeding certain. 

Best method is to use fresh blood. 

Minot — Prei^are slide with film of cresyl blue 
(1-300) dried. This will keep a long time. 
Secure drop of blood upon a coyer-slij) inyert 
upon the prepared slide. Platelets and retic- 
ulated forms show well. The platelets stain a 
characteristic blue. 

2. Determine the bleeding time. 

Vena puncture (Dr. Howell). Be sure to hit 
the yein on the first try. 1 cc. of blood in a 
clean tube (8 mm. in diameter). Xormal blood 
can be inyerted in 7-10 minutes. Also note 
when the first signs of coagulation begin (slight 
concayity). The length of the coagulation time 
does not run parallel Ayith the tendenc}' to hem- 
orrhages. 

3. Retractility and Firmness of the Clot. 

In hemorrhagic states either failure to re- 
tract, or soft, fiabby clot occurs. Flabby clot 



N 



indicates decreased thrombin or fibrinogen. 
Xon retractilit}^ indicates decreased platelets. 
Sometimes "reclottiug" occurs. Remove clot 
and serum again clots. 

This is associated Avith lack of retractility. 
4. Other studies of mucli value when possible are : 

1. Effect of addition of calcium on the coagu- 
lation time. 

2. Determination of the pro thrombin time. 

o. Determination of the anti thrombin and 

fibrinogen. 
4. Determination of fibrinolytic ferments. 
Purpura Simplex. 

This is a disease with skin symptoms exclusively 
and slight pains. There may be a few eruptions 
coming out in crops. Duration 6 to 8 weeks. 

Purpura Rheumatica or Schonlein's Disease, 
Peliosis Rheumatica. 

The term has been horribly misused. It is applied 
to any condition of arthritis with purpuric, erythe- 
matous, or urticarial lesions. It is best to adopt 
the term ''Simple purpura with arthritis." 
Clinically : 

1. Young adult males. 

2. Average duration, five weeks. 

3. Recurrent arthritic signs, polyarticular rheu- 
matism, especially of the knees and ankles. 

4. Simple purpura. 

5. Fever slight or absent. 

0. ^^ever fatal. 

7. History of previous rheumatic fever, rare. 

8. Salicylates not helpful. 

9. Purpuras rare in true rheumatic fever. 

10. Association of urticaria, erythema, and angio 
neurotic oedema. 

Henoch's Purpura. 

1. Recurrent purpura. 



250 

2. Abdominal crises, melena, hematemesis. 

."). Arthritis coiiijnon. 

4. Nephritis coinmoii aud severe. 

Occurs iu males in early life. Recurrent attacks. 
Beware of early operations. 

Blood picture. Purpura simplex, Purpura rheu- 
matica, and Henoch's Purpura differ only in de- 
gree, frequency and extensiveness of the purpura. 
S. A. picture, platelets normal or increased. No 
coagulation disturbances evident. 

Purpura Hemorrhagica — Aplastic Anaemia. 

The condition is idiopathic or acquired, acute, 
subacute, or chronic. Tendency to hemorrhages 
under the skin and mucus membrane anyAvhere. Skin 
eruptions, diminished blood platelets. Delayed 
bleeding time. Xon-retractility and often flabby 
clot. Often true hereditary tendency. 

Aplastic Anaemia. 

This is a true disease entity. It is acute with pro- 
gressively downward course (3 to 6 weeks). Occurs 
in young males. Rarely associated with arthritis. 
Clinically there is no evidence of blood destruction. 
Some unknown toxic substance inhibits all the mye- 
loid elements. C. I. below 1. (.8 to .9.) Platelets 
absent, or, if not absent, curiously large. Leuco- 
paenia, lymphocytes increased relatively. Tendency 
to purpura, but not to bleeding. In PurjDura hem- 
orrhagica only one myeloid element is inhibited, 
i. e., platelets. The white count is increased with 
true P. M. N. increase. Other myeloid elements show 
increase. Signifies intravascular destruction. Both 
diseases. Purpura Hemorrhagica and Aplastic Anae- 
mia, occur in same people. Some cases of the 
former turn into the latter. 

1. Aplastic Anaemia — complete, rapid myeloid de- 
struction. 

2. Purpura hemorrhagica : 



251 

(a) Contiuiious: 1. Acute (3 days). Always 
tiud platelets below uormal. 2. Chronic. 

(b) Intermittent. Clears up and then returns. 
Platelets low only during attack. 

3. Intermediate Group. 

Intermittent type. There is a tendency for- 
the platelets to decrease. It does not go onto 
true aplastic anaemia. 

Other Diseases. 

Hemophilia. A blood deficient in pro thrombin 
and a true or relative excess of antithrombin. Plato- 
lets normal. Mendelean heredity. 

Scurvy — unbalanced diet, bleeding tendency, loose 
gums. Often cured by introducing suitable food. 
Xo disturbed coagulation picture. 

Barlow's Disease — Infantile Scurvy. This is a 
periosteal affair, occurring in the lower extremities. 
It is characterized by pain in the bone. Look for 
it in children who stop walking. 

Essential hematuria. See notes on urine. 

MATCHING OF BLOOD FOR TRANSFUSION 

Hemol^^sins : 

1. Traumatic. 

2. Toxic. 

Other classification : 

1. Heterologous. Exemplified by rabbit and sheep. 

2. Autohemolysis — • rarely autoagglutination — 
noted in R. B. C. counting. 

3. Isohemolysis — 90% possess isoagglutinin ; 25% 
isohemolysis. 

Grouping is established by the time the individual 
is two years old and remains unchanged throughout 
life. 



252 



Red Blood Cells 


of T. 


TI. TIT. IV. 


. Serum I. 








(10%) 






Serum II. 


+ 


+ 


1^0%) 






Serum III. 


+ 


+ 00 


(7%) 






Serum IV. 


+ 


+ + 


(i3%) 






Even by gross 


methods one can tell whether agglu- 


tination takes place or 


not. 



Method of matching blood. 

1. Cross agglutination. Obtain serum from each 
patient; also corpuscles washed twice with iso- 
tonic salt solution and resuspended in salt solu- 
tion to make a faint pink color. Place a drop 
of the receiver's serum upon a cover-slip and 
near it a drop of the donor's r. b. c. Also place 
a drop of the patient's r. b. c. upon a cover-slip 
and near it place a drop of the donor's serum* 
With a small glass rod mix the first two drops, 
and with another glass rod mix the second two 
drops. Invert the cover-slips and place over 
hollow-ground slides well sealed with vaseline. 
Examine immediately microscopicall}^, and 
again in an hour. Exclude any donor whose 
cells are agglutinated by the receiver's serum 
or whose serum agglutinates the receiver's 
blood. Usually members of the same group 
match, but this method is the safest because, 
sometimes, groups do not match, especially in 
severe anaemias. 



253 



2. Using known sera or 



b. c from groups II. 



and III. 



Corpuscles. 
Group IT. Group III. 



Serum of pt. 





a kt 





u u 


Agg. 


a a 


Agg. 





Group of pt. 
I. 
II. 
III. 
IV. 



Agglutination 



No Agglutination 



Serum. 
Group IT. Group III. 



R. B. C. of pt. 



Agg. 


Agg. 





Agg. 
Agg. 







Group of pt. 
I. 
11. 
III. 
IV. 



After finding a donor of the same group as the 
patient, match their corpuscles and serum as in 
proceedure 1. 

The serum may be preserved at least a year if 
kept on ice. 

Members of Group I. may be universal recipients. 

Members of Group IV. may be universal donors. 

Members of Group IV. should only get Group IV. 
blood. 

Group IT. and ITT. very serious. 

The amount given at a transfusion varies from 500 
cc. to 3 liters. 

CEREBROSPINAL FLUID 
Up until 1891 no particular importance was placed 
in spinal fluid examinations but now very important 



254 

clinical evidence can be obtained thereby. The ex- 
istence of a tnnior at tlie base of the sknll is only 
real contraindication advanced against Innibar pnnc- 
ture. 

Postnre — lying down. 

8ito of pnncture— P>-4 or 4-5 hnnbar spines. 
Two methods of entrance — mid-line or to right or 
left of mid-line. 

Only discomfort is going through skin. 
There are about 40 to 70 cc. in the average in- 
dividual. 5 cc. is ample for an examination, 2-3 cc. 
are enough. 

Avoid lumbar i^uncture reaction, which consists 
of severe headache, head pulling backward — relieved 
by lying down. Often dizziness and nausea follow, 

(rood routine: 1. Have patient plan to stay in bed 
for 24 hours following, with only one pillow. 2. For 
tlrst four hours a glass of water every hour. o. 1 cc. 
of pituitary extract immediately after puncture. 4. 
Patient should sit quietly two or three hqurs after 
the 24, then move about the house, and, upon tlie 
slightest evidence of headache, go back to bed. 

Normal Spinal Fluid. 

Clear, colorless, sparkling, resembles distilled 
Avater. Normal pressure varies with posture, but 
markedly increased in certain diseases. 120-140 mm. 
H20, 6-10 mm. Hg. 

Increased : 

1. Acute meningitis. 

2. Poliomyelitis and tbc. meningitis. 

3. Intracranial pressure. 

In some cases absolutely diagnostic, but in most 
only confirmatory. 

Inorganic constituents : 

Chlorides— .5 to ,6 gm. per 1000 cc. 



255 
Organic constitueuts : 

Dextrose — .4 to .6 gm. per 1000 cc. 

Complete absence in C. S. meningitis — of value. 

Notable increase in diabetes. 

Protein — probably serum globulin, no readily 

demonstrable amount of protein. 
Keactions : 

1. Noguclii — butyric acid. 

2. Koss-Jones — saturated ammonium sulphate, 
faint rings between substances. 

3. Pandy's — aqueous saturated carbolic. Normal 
spinal fluid shows no cloud with 1 drop, almost 
imperceptible with 10. Abnormal fluid shows 
milk}' ppt. Exclude blood. 

Increase in protein abnormal, but not specific for 
any condition. In acute inflammatory conditions 
of central nervous system, severity usually runs 
parallel Avith protein increase. Depends upon loca- 
tion. In syphilis there is increase in globulin. 

Cytology : 

1-5 cells per c. mm, usually of the S. M. type. 8-12 
cells, probably an increase. Above 12 cells distinctly 
abnormal. 

Method of counting : Cell counts should be made 
as soon as possible, for they settle quickly and de- 
generate. The white pipette is used and is filled up 
to 1 with stain. Giemsa is good as well as .2% 
methyl violet in water. The uncentrifugalized fluid 
is then drawn up to 1 1 . Shake thoroughly and count 
on Fuchs-Rosenthal counting chamber. The cham- 
ber contains 3.2 c. mm. of fluid. Count all white 
cells in entire ruled area, multiply by 11 and divide 
by 32. An ordinary counting chamber can be used 
with the same method of staining. In this case an 
entire large square is counted and the result multi- 
plied by 10, or all gf the 9 large squares can be 



256 

counted, an average taken, and the result multiplied 
by 10. 

Increased in : 

1. Infectious meningitis conditions. Usually P. 

^i. X. increase. Fluid cloudy. 
:. The. meningitis. Fluid clear. JS. M. increase. 
.'). Syphilis. S. M. increase. Cell increase means 
irritated surface. 

4. Tabes. Normal or increased. 

5. Paresis. S. M. increase. 

In tbc. meningitis it is usually possible to find the 
organism. If the fluid is allowed to stand over night 
in an ice-chest the organisms will often be found in 
the |)ellicle which forms. 

In syphilis of the C. N. S. the Treponema pallidum 
lias been found repeatedly, Avith the dark field illu- 
mination. 

In infective meningitis it is the rule to find the 
causative organisms in stained smears. 

Much of the interest in the spinal fluid examina- 
tion centers around the Wassermann action. The 
disease may become localized in the C. X. S. and the 
blood give a negative reaction Avhile the spinal fluid 
gives a positive. A positive Wassermann is never 
found in a S. F. which is globulin free. The test is 
positive in about 100% of paretic tj^pes, 60% of tabe- 
tic, and 80 to 85% of all C. X. S. lues. After therapy 
there is at first abundant i)rotein, which tends to de- 
crease. A positive Wassermann may remain in spite 
of protein decrease; this is called ''Wassermann 
fast." Therapy should be continued till the S. F. 
returns to normal. 

Xanthochromia. This is a rare finding where the 
S. F. is a yellow color, a marked cell increase, and 
the fluid iindergoes spontaneous coagulation. The 
cause is a tumor in the spinal cord. 



257 

Colloidal Gold Reaction. 

This reaction depends upon the globulin and al- 
bnniin content of the spinal flnid in certain quanti- 
tative proportions. It is not specific for syphilis, 
but is of clinical value for its diagnosis neverthe- 
less. 

^lethod of preparing tbe gold solution (L. D. Fel- 
ton, J. A. M. A. 1917, pg. 73-92.) The glassware 
should be thoroughly cleaned as follows : 

1. Boiled in an ivory soap solution for half an 
hour. 

2. Brushed, rinsed and filled Avitli sulphuric acid- 
bichromate mixture. 

3. Just before use the beaker is emptied and 
rinsed for two minutes with tap water and five 
times with singly distilled water. Glassware so 
cleaned can be used for colloidal gold work as long 
as a month if it is used for nothing else. 

Preparation of Distilled Water : 

One cc. of a 10 per cent solution of potassium 
permanganate and 1 cc. of a saturated solution of 
barium hydroxide are added to two liters of the 
water to be distilled. The first quarter of the dis- 
tillate as well as the last are thrown away. Water 
thus prepared can be stored away in hard glass 
containers for an indefinite time. 
Reagents: 

Chemically pure potassium carbonate, 2 gm. to 
100 cc. 

Chemically pure gold chloride, 1 gm. to 100 cc. 

Chemically pure formaldehyde, 1 :40. 
Technic for 1000 cc. : 

Gold chloride, 100 cc. 

Potassium carbonate, 8 cc. 

Formaldehvde, 6 cc. 



258 

The potassium carbonate and gold chloride are 
added to the beaker of cold >Yater. The contents of 
tlie beaker are then heated nntil they boil briskW 
and then the formaldehyde is added drop by drop 
until the development is almost complete, when the 
remainder of the formaldehyde is thro^vn in. Stir- 
ring is unnecessary. Should the solution become 
very alkaline after long standing it should be cor- 
rected according to Miller and his associates (Bull 
Johns Hopkins Hos. 1915, 26, :39i.) 

The Colloidal Gold Test: 

"Into the first of 11 clean test tubes, reserved es- 
pecially for that purpose, put l.S cc. of fresh, sterile 
0.1 per cent NaCl solution. Into each of the remain- 
ing 10 tubes put 1 cc. of salt solution of the ame 
strength. Xow add to the first tube, by mcaiu of a 
clean, dry, certified 1 cc. pipette, 0.2 cc. of -!-3 spinal 
fluid to be tested. Mix well. Transfer 1 cc. of the 
resultant 1 to 10 dilution of spinal fluid to the sec- 
ond tube, and again mix thoroughly and transfer 
1 cc. of this dilution to the third tube. Proceed in 
this manner up to and including the tenth tube. By 
this method a series of dilutions of the spinal fluid 
is secured, in geometrical progression, ranging from 
1 to 10 to 1 to 51 20. Xow add to each of the 1 1 tubes 
5 cc. of a suitably prepared and standardized col- 
loidal gold solution, shake each tube thoroughly and 
set the series of tubes aside for subsequent observa- 
tions. It will be noted that the eleventh tube serves 
as a salt control, since it contains no cerebro-spinal 
fluid." The series can be read fairly accurately with- 
in an hour, as little change occurs after that time. 



259 







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260 

TEEMS, ETC., USED IX THE CLASSIFICATION 
OF PAEASITES. 

1. Kingdom — as Animal, Vegetable. 

2. PliyJuith or Branch — a ijrimary division of the 
animal or vegetable Kingdom. 

Ex.: Protozoa. Artliropoda or Tcrtelrata. 

3. Class — the division next below the Plujlum. 
Ex. : Insecta or FJageUata. 

4. Order — the division next below the Class) and 
made up of a group of Families agreeing closely in 
some striking characteristic. 

(There is no fixed, systematic termination for the 
divisions above that of the Superfamily, but, as seen 
from the examples given, many of them end in a. 

Ex. : Hacmosporidia or Dipt era. 

5. Superfatvily — the division next below the Order. 
Always terminates in oidea. 

Ex.: Ixodoidea ( — ■ Ixodidae (family) plus Arga- 
sidac (family). 

6. Family — the division next below the Super- 
family. The name is formed by adding the ending 
idae to the root of the name of the type genus. In 
printed matter the family name should appear in 
Eoman type. 

Ex. : Strongylidae or Culicdae. 

7. SuhfamHy — the division next below the Family. 
The name is formed by adding the ending inae to 
the root of the name of the type genus. 

Kote — Not all Families are divided into Suhfami- 
lies, or grouped into Superfamilies. 
Ex. : Strongylidae or Culicrae. 

8. Genus — the division next below the Siih family. 
Separate species of animals which agree in the main 
characteristics of size, proportion of parts and gen- 
eral structure are placed in the same genus. Each 
genus usually contains several species, but may have 
only one. The generic name should be Greek or 



261 

Latin, preferabh' a noun, in tlie nominative, singu- 
lar: it should be invariably spelled with a capital 
letter. 

Ex.: Ascaris or Culex. 

9. Species — the division next below the Genus. It 
consists of animals in all respects alike or which 
differ in only minor details. (The male and female 
of a species may be unlike, but in mating they pro- 
duce young having characteristics similar to those 
of the parents.) The specific name should be : 

1. A noun in the genitive, or 

2. An adjective, which should agree in gender, 
case and number with the generic name. (Ex- 
ception — may have a masculine noun as the 
specific with a feminine generic name.) 

3. A modern patronymic — 

= Complete name plus i for a man. 
= Complete name plus ac for a woman. 

4. Always spelled with a small letter. 

In naming a species, the name of the genus is 
always written first, with a capital letter, followed 
by the specific or descriptive term, with a small let- 
ter. When 'printed^ both should be in italics; when 
tvritten^ both are underscored — 

Ex.: Ascaris himhricoides or Musca domestica. 

Type Species — the species of a genus always re- 
ferred to as representing the genus. Other species 
may, for good reasons, be transferred to another 
genus, but the type species is permanently in the 
genus. Many favor reduplication in the naming of 
the t^'pe species, as 

Heteropliyes heteropliyes. 
USEFUL BIBLIOGRAPHY IN PARASITOLOGY. 

1. C. W. Stiles- 
Articles in Osier's Modern Medicine. 

2. Minchen— 

An Introduction to the Stud}^ of Protozoa. 



262 

3. G. W. Calkins— 
rrotozooclogy. 

4. Doflein— 

Lehrbnch der Protozoenkunde, 3rd Edition. 

5. Y. Prowazek — 

Handbiicli der patliogenen Protozoen. 

6. Kolle U. Wassermann — 

Handbucli der patliogenen Mikroorganismen. 
(Edition, Vol. VIL). 

7. Braun — 

The Animal Parasites of Man. 

8. Fantham, Stephens and Theobald — , 
The Animal Parasites of Man. 

9. Blanchard — 

Traite de Zoologie Medicale. 

10. Leuckart — ■ 

Die Parasiten des Menschen. 

11. Stitt— 

Practical Bacteriology, Blood Work and Ani- 
mal Parasitology, 1th Edition; Diagnostics 
and Treatment of Tropical Diseases. 

12. Castellani and Chalmers — 

Mannal of Tropical Medicine, 2nd Edition. 

13. Patrick Manson — 

Tropical Diseases, 5th Edition. 

14. Mense — • 

Handbuch der Tropenkrankheiten, 2nd Edi- 
tion. 

15. Herms — ■ 

Medical and Veterinary Entomology. 
CLASSIFICATION OF THE MORE IMPORTANT 
PARASITES OF MAN. 
Group I. — Protozoa (Phylum). 
Class A. — Rhizopoda or Sarcodma. 

A class of Protozoa whose functions of locomotion 
and prehension are performed by temporary protru- 
sions of protoplasm called pseudopodia. 



263 

A. Order — Gymxamoeba. 
(Jc'iius — Endiunoclja. 
Species : 

1. E. coli — uoii-patliogeuic. 

2. E. liistoUjiica — (Includes E. tetragena) — 
Amoebic clyseutery; Liver abscess. 

Class B. — FJagellata or Mastigopliora (to wear a 

whip ) . 

A class of Protozoa in which flagella or undulat- 
ing membranes serve the functions of locomotion 
and prehension. ' 

(1). Genus — Spirochaeta or Spiroscliaudiiuiia. 
Speci-es : 

1. S. rccurroitic — (S. obermeieri) — European 
relapsing fever.- | 

2. S. duttoiii — African relapsing fever. 

3. ^. cartcri — Asiatic relapsing fever. 

4. S. novyi — American relapsing fever. 

5. ^. refringens. 

6. S. vuiccnti — Vincent's angina. 
(2) Genus — Treponema. 

Species : 

1. T. pallidum — Syphilis. 

2. T. pertenue — Yaws. 
(8) Genus — Trypanosoma. 

Species : 

1. T. qanMense. ) ^^ . . , 
^ „ , ^ . V Sleeping sickness. 

2. T. rJwdesiense j 

( 4 ) Genus — Sch izotrypa num. 
Species : 

1, S. cruzi — Brazilian tiwpanosomiasis. 

( 5 ) Genus — Leishm a nia . 
Species : 

1. L. donoixini — Kala-azar. 

2. L. tropica — Oriental sore. 

3. L. infantum — Infantile splenomegaly. 

(6) Genus — Balyesia. 



264 

Species : 

1. B. higcmina — {Piroplasma higeminum) — 
Texas fever of cattle or Ked water fever. 

(7) Genus — Trichomonas. 
Species : 

1. T. vaginalis. 

2. T. intestinals. 
Flagellate diarrhoea. 

(8) Genus — Lamhlia. 
Species : 

1. L. intestinalis. 

Flagellate diarrhoea. 

(9) Genus — Cercomonas. 
Species : 

1. C. hominis. 

Flagellate diarrhoea. 
Class C. — Infusoria or Ciliata. 

A class possessing contratile vacuoles and numer- 
ous fine cilia which are shorter than fiagella and 
Jiave a sweeping stroke. 

A. Order — Heterotricha. 
Genus — Balantidium. 
Species : 
1. B. coli. 
Class D — Sporozoa. 

These possess no motile organs. They live as para- 
sites in tissues and cells of other animals. Keproduc- 
tion by spores.- 

A. Order — Coccidaria. 

(1) Genus — Eimeria. 
Species : 

1. E. stiedae. 

(2) Genus — Isospora — Luci. 
Species: 

1. /. J)igemina. 



265 
B. Order — Haemosi'ORIdia. 
GeiiiiH — Plasmodium. 
Species : 

1. P. vivax — Terian malaria. 

2. P. malariae — Quartan malaria. 

3. P. falciparum — (Laverania malariae) — 
AestiA'o-autumnal malaria. 

c. Order — Sarcosporidia. 
Genus — Sarcocystis — Stuntu etaoin 
Species : 
1. S.— ?. 

Group II. — Vermes (Phylum) worms. 
Class A. — Platyhelminthes or Platodes. 

Flat worms. Divided into two main orders. 

A. Order — Trematoda or Trematodes. 
Flukes — possess intestine, but no anus; one or 
two suckers present: body never segmented nor cili- 
ated. Order divided into three main families. 
1. Fasciolidae (family). 

Two suckers, one terminal, the other adjacent to 
it; situated ventrally; hermaphroditic. 

(1) Genus — Fasciola. 
Species : 

1. F. hepatica — Liver fluke disease — Hepa- 
tic distomiasis. 

(2) Genus — Fasciolopsis. 
Species : 

1. F. 'buskii — Intestinal distomiasis. 

(3) Genus — Dicrocoelium. 
Species : 

1. D. lanceatum — He}3atic distomiasis. 

(4) Genus — Parngonimus. 
Species : 

1. P. iv ester manii — Pulmonary distomiasis 
— Parasitic haemoptysis. 

(5) Genus — Clonorchis. 



I 



266 

impedes : 

1. C. Hnivii^ls — Japanese liver (luke disease. 
(<)j Genus — pi sth orchis. 
Species : 

1, 0. felineus — Siberian liver fluke disease. 
(7j Genus — HeteropTiyes. 
Species : 

1. H. lieteropJiyes — Intestinal distomiasis. 

2. Paramphistomidae (family). 

Two suckers, one at either extremity ; hermaphro- 
ditic. 

(1) Genus — Gastrodiscus. 
Species : 

1. G. hominis — Intestinal distomiasis. 

3. Schistosomidae (family). 

Leaf-like male which by a folding-in of its sides 
makes a channel for the thread-like female. Sexes 
separate. 

(1) Genus — Schistosoma. 
Species : 

1. S. haematoMum — (African blood fluke). 

2. S. japonicum — (Asiatic blood fluke). 

3. S. mansoni — (West Indian blood fluke). 

B. Order — Cestoda. 

Tapeworms; intestine absent; 2 to 4 suckers on 
head; adult body segmented and parasitic in intes- 
tine; larvae are parasitic elsewhere. Two main 
families. 
1. Taeniidae (family). 

Head with four cup-like suckers; genital pores 

lateral. 

(1) Genus — Taenia. 
Species : 

1. T. solium — (Pork or armed tapeworm). 

2. T. saginata — (Beef or unarmed tape- 
worm ) . 

Hydatid disease. 



267 

(2) Genus — DipijUcUiiiH. 
Species : 

1. D. caninnni — {Tdcnia cucumerUia ; the 
double pored or dog tapeworm). 

(3) Geuus — Hytnenolepis. 
Species : 

1. H. nana — {Taenia ;/(///(/; the dwarf tape- 
worm). 

2. H. ditnijiuta — {Taenia diniinuta ; Hijme 
nolepis flavopiuictata ; the rat tape- 
worm ) . 

2. Dihoihriocephalidae (famihO. 

Head with two elongated slit-like suckers ; median 
genital pores ; ventral, median, rosette uterns ; 
single set of genital organs in each segment. 
Genus — Dihothriocephalus. 
Species : 

1. D. Jatus — (the broad or fish tapeworm). 
Class B. — Xemathelminthes. 

Round worms, covered with a cuticle which is 
often ringed ; well developed alimentary canal ; 
sexes are usually separated ; males smaller in size, 
posterior end curved or curled, sometimes show- 
ing umbrella-like swelling, the copulatory bursa ; 
genital opening in the male near anus, in female 
midway; develop as a rule in damp earth from 
the eggs as rhabditiform larvae; a few are vivi- 
parous. Families important to man are: 
A. Order — Xematoda or Nematodes. 
1. FiJariidae (family). 
(1) Genus — Filaria. 
Species : 

1. F. 'bancrofti — {F. sanguinis hominis; 
F. nocturna) — Filariasis ; Elephantia- 
sis (?). 

2. F. loa. 

3. F. perstans. 



268 

(2) (reuiLs — Dracuucnlu^. 
X peek's : 

1. D. medinensis — Guinea worm ; "Fiery 
serpent" (?). 
Angiostomidoe (family) . 
Genus — Strougyloides. 
Species : 

1. S. stercoralis — Cochin China diarrhea. 
Trichinellidae (family). 

( 1 ) Genus — Trich inella. 
Species : 

1. T. spiralis — [Trichina spiralis) ^Trichi- 
niasis. 

(2) Genus — Trichiuris. 
Species : 

1. T. trichiura — (TricJwcephahis dispar ; 
whipworm). 
Strongylidae (family) . 

( 1 ) Genus — Ancylo stoma. 
Species : 

1. A. duodenale — Old World hookworm). 
Uncinariasis or Hookworm disease, 

(2) Genus — Xecator. 
Species : 

1. Kecator americanus — (New World hook- 
worm). Uncinariasis or Hookworm dis- 
ease. 

( 3 ) Genus — Trich ostrongylus: 
Species : 

1. T. instahilis — Parasite of sheep and 
goats; accidental, but harmless parasite 
of man ; eggs may be mistaken for hook- 
worm ova. 

(4) Genus — Dioctophyme. 
Species : 

1. D. renale — (Eustrongyliis gigas; the dog 
kidney Avorm). 



269 

5. Ascaridae (family). 

Xo intermediate host uecessary. 

(1) Genus — Ascaris. 
Species : 

1. A. lunil))icoides — Eel worm) — Ascaria- 
sis. 

(2) Genus — Toxocara. 
Species : 

1. T. canis — [Ascaris mijsfa.r; Toxascaris 
niystax ; Belascaris mystax ; the clog as- 
caris or eel worm ) . 

(3) Genus — Oxyuris s. 1. or Entei'ohius. 
Species : 

1. 0. vennicularis — E. vevmicularis ; pin- 
worm or seatworm. . 
Group III. — Arthropoda (Phylum) — 
( jointed-limbed invertebrates) . 
Class A. — Arachnoidea. 

(Resembling a spider.) These have the head and 
thorax fused together ; possess four pairs of am- 
bulatory appendages ; never have compound eves ; 
chitinous exoskeleton : no antennae ; body is often 
segmented ; respiration is by tracheal tubes. Those 
of chief interest belong to the general order Aca- 
rina, which includes chiefly the mites and /^^icArs. 

(1) GemvL'^-Sar copies. 
Species : 

1. S. scahiei — (Itch mite) — Scabies or ''the 
itch." 

(2) Genus — Dcmodex. 
Species : 

1. D. foUiculorum. 

(3) Genus — Leptus. 
Species : 

1. L. autiuiinaJe — (Harvest bug or "chig- 
ger"). 



270 

Class B. — Jnsccta. 

Possess one pair of antennae, three pairs of month 
parts and three pairs of legs. The body is divided 
into tlu-ee parts — head, thorax and abdomen. Usn- 
ally have two pairs of wings. Most insects show 
metamorphosis ; ova develop into voracions, worm- 
like /(// vac; then follows the encased pupa stage, 
and this finally tnrns into an imago or fnlly de- 
veloped insect. The following are important in 
their relation to man : 

A. Order — Su'huxculata 
(Flat; Avingless ; no metamorphosis.) 

1. Pcdiculidae (family). 
( 1 1 (ienus — Pediculus. 
Species : 

1. F. capitis — (Head lonse). 

2, P. vestinicnti — (Body lonse). Pedicnlosis 
( 2 j . ( ienus — Pli th irius. 

Species : 

1. P. piihis — {Phthirius inguiiialis; Pedicu- 
lus piihis; Crab louse). Pediculosis. 
B. Order — Heimiptera or Khynchota. 
Insects possessing a sucking beak ; metamorphosis 
not marked. 
]. Gimicidae (familj). 
Genus — Cimex. 
Species : 

1. C. lectularius — (Acanthia lectularia; the 
bed-bug). 

c. Order — Siphoxaptera 
Laterally flattened, wingless insects which undergo 
complete metamorphosis. 
1. Pulicidae (family). 

(1) Genus — Pulex. 
Species : 

1. P. irritans — (European human flea), 

(2) i^^nw^-^Ctenoceplialus. 



271 

Species : 

1. C. canis — [C. serratlceps; American dog 
and human flea). 

(3) Genus — ^arcopsylla. 
Species : 

1. S. penetrans — (Pulex penetrans; Trop- 
ical sand flea; "chigger"). 

(4) Genus — Xenopsylla or LaemopsyUa. 
Species : 

1. A^. chcopis — (LaemopsyUa clieopis ; rat 
flea of India; plague flea). 

(5) Genus — Ceratophyllus. 
Species : 

1. C. fasciatus — (Rat flea.) 

D. Order — Diptera. 
Have distinct mouth parts — for biting or sucking ; 
undergo complete metamori^hosis ; possess one pair 
of wings ; other pair usually rudimentary. 

1. Culicidae (family). 

(1) Genus — Culex. 
Species : 

1. C. quinquefasciatiis — (C fatigans; House 
mosquito ) . 
Transmits : 

1. Dengue fever. 

2. FiJaria hancrofti. 

3. Proteosoma infection of birds. 

(2) Aedes or Stegomyia. 
Species : 

1. A. calopus — {Stegomyia calo pus; S. fas- 
ciataQ — Transmits fellow fever. 

(3) Anopheles. 
Species : 

1. A. rnaciilipcnnis — Transmits malaria. 

2. Muscidae (family). 
(1) Genus — Glossina. 



272 

Species : 

1. G. palpalls — Transmits sleeping sickness 
Trypanosoina gamhiense. 

2. G. morsitans — Transmits Trypanosoma 
rJiodcsiense and Trypcmesoma hrucei. 

(2) (lenus — Stomoxys. 
Species : 

1. S. calcitrans — (Stable fly). 
( :> ) Genus — Musca. 
Species : 

1. M. domestica — (Common house fly). 



273 

En (la mocha histolytica. 

Two forms of the amoeba occur in the stools, the 
mobile and the encysted. In examining the feces for 
this organism it is best to pick out a bloody particle 
of mucns if such is present, make an emulsion with 
a small amount of salt solution upon a glass slide, 
place a cover-slip over it and examine Avith low pow- 
er for small retractile bodies. If such are found 
tlieu examine AvJtli the high power for confirmation 
and details. 

Wa'lker's table for dift'erentiating E. Coli and E. 
Histolytica. (Barker Vol. II. page 421.) 
Mobile stage. 
E. histolytica. 

1. Appearance hyaline. 

2. Kefractiveness more feeble. 

0. Movements active in fresh stool. 

4. Nucleus more or less indistinct. 

5. Chromatin of nucleus scanty. 

E. coli. 

1. Appearance porcelaneous. 

2. Kefractiveness pronounced. 

3. Movements sluggish. 

4. Nucleus distinct. 

5. Chromatin of nucleus abundant. 

Encysted Stage. 
E. histolytica. 

1. Cyst smaller. • • • 

2. Cyst less refractiAe. 

3. Usualh^ contains elongated refraction bodies 

knoAvn as "chromidial bodies." 

4. Nuclei never more than four. 

5. Cvst wall thinner. 



274 

E. coll. 

1. C^'St larger. 

2. Cyst more refractive. 

3. Cysts do not contain "cliromidial bodies.' 

4. Nuclei 8, occasionally more. 

5. Cvst wall thicker. 



In general it may be said that when one finds an 
amoeba with phagocyted r. b. c. one should suspect 
a pathogenic form. This does not always hold true 
but is fairly reliable. Coli may contain one or two, 
while histolytica usually contains a great many. 

Pathology — The amoeba attack most frequently 
the upper part of the large intestine, where tluy en- 
ter the crypts of the mucosa and produce small 
necrotic areas. From here they invade the sub- 
mucosa and undermine smaller or largr patches. 
The organism frequently find their way into the liver 
and produce abscesses tiiere. 

Diagnosis — The finding the amoeba in the stools. 
Trypanosoma gambiense. 

Size — 18 to 25 microns by 2 to 21/2 microui-'. 

Pathology — The organism enters the circulating 
blood and at first causes a varying febrile condition. 
Later the patient goes into the sleeping-sickness 
proper, which condition is hopeless. 

Diagnosis — Make stained preparations of the 
blood. If the organisms are few a method of con- 
centrating the organisms can be carried out as fol- 
lows : ^Lake a vena puncture and draw ofl:* about 
15 cc. of blood into :> cc. of a 2.5 per cent solution 
of sodium citrate in N/NaCl, which will prevent it 
from clotting. Centrifugalize and draw off cellular 
elements, make smears and stain, as follows : Add 
acid alcohol to fix smear and remove hemoglobin al- 



275 • 

lowino: to stand 30 minutes to 2 hours. Wash in 
running water for half to two hours to remove all 
acid. Dry in the air and stain with Romanowsky 
stain. A surer method is to inject rats with a small 
amount of blood and examine rat's blood for the 
parasites. 




Lmnhar Puncture — The organisms are present in 
the second stage of the disease. Draw off fluid, 
centrifugalize and examine sediment. 

Gland Puncture — Aspirate a suspected gland with 
a hypodormic needle. A surer method is to remove 
a gland and examine or inject preparations of it into 
rats. 

Mode of Infection — Through the common fly, 
Glossina palpalis. There are two methods of trans- 
mission. 

1. Immediate or direct. 

2. Indirect. A sexual type of development takes 

place Avhich requires an average of 24 days for 
the fly to become infective. This can be 
varied by change in temperature. The fly is 
infective as long as he lives. 

Trichomonas intestixalis. 
This organism is probably the same as Tricho- 
monas vaginalis. It is found in the vagina, urethra, 
large and small intestine, stomach and sputum. 
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Lamblia intestinalis. 

other names — Megastoma entericum, Hexcunitus 
duodenalis, Dimorplins muriSy Megastoma intesti- 
nale. 

Size — 15 to 10.5 micvons by 10 to 12 microns. 

Pathology — Non-pathogenic. Large numbers often 
occur in the feces. 




Balantidium coli — (Paramoecium coli). 

Size — 70 to 100 microns by 50 to 70 microns. 

Pathology — Often found in connection with vari- 
ous types of diarrheal affection but may be found in 
persons without intestinal symptoms. It is capable 
of setting up a severe ulcerative colitis not unlike 
amoebic dysentery (Strong and Bowman) and se- 
vere anaemia (Barker). 




279 

Fasciola hepatica. 

other names — Distomum hepaticum, Distomum 
cam, Fasciola huinana, Cladocaelimn Tiepaticum, 
common liver fluke. 

^*i^e_20 to 50 by 8 to 13 millimeters. 

^ize of egg — 130 to 145 microns by 70 to 90 
microns. 

Pathology — Usual habitat is the gall ducts but is 
frequently found in the gall bladder, intestines, por- 
tal system, and subcutaneous cysts. Infection is 
rare in man (32 cases recorded). 

Mode of infection — The intermediate host is the 
snail of the genus Limnaea. Infection occurs in 
swallowing the encysted cercaria deposited on plants 
in marshes. 

Method of diagnosis — Finding ova in the feces. 





. SCHISTOSOMUM HEMATOBIUM. 

(Infection called Distomiasis and Bilharziasis) 

Other names — Bilharzia hematohia, gynecophorus, 
Distomum hem^atoMiim, Distoma capense, Thecoso- 
ma. 

Size of male — 12 to 15 mm. by 1 mm. 

Size of female — 20 mm. by 0.25 mm. 

Size of eggs — 0.16 mm. by 0.05 mm. 

Pathology — The parasites inhabit the blood of the 
portal vein, and the vessels of the pelvis, rectum and 
bladder. 

Mode of infection — Through drinking water and 
occasionally through the skin with a cycle much like 
that of the hook-worm. Egg cysts form in the mu- 



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282 

cosa of the bowel and bladder, causing lieiuorrliagcs 
from either. 






S. hematobium S. joponicnm S. manisoni 

Paragonimus westermanii. 
This organism is a very frequent cause of he- 
moptysis in Japan. The eggs can be found in the 
unstained sputum which are j^ellow, operculated, 
and 77 to 102 by 40 to 75 microns in size. 

FiLARIA BANCROFT!. 

Size — 270 to 340 microns long by 7 to 11 microns 
broad. 

Pathology — These parasites and their ova cause 
obstruction of the lymphatics. They reach the gen- 
eral circulation bj^ way of the thoracic duct. 
Chyluria is a very frequent occurrence due to the 
rupture of the varicose lymph vessels of the bladder. 
Elephantiasis develops in the extremities due to 
lymph obstruction. 

Method of diagnosis — There is usually pain and 
fever with lymph tumor, elephantiasis, hematochy- 
luria, enlarged spleen. Examine the blood during 
the night for the parasites, for they appear in the 
circulation onlv at this time. 




Strongyloides stercoralis. 
Other names — Anguilhda intestinalis et stercor- 



283 

alis^ Leptodera, intcsfinaJis et stercondis, Pscudor- 
hahditis stercoralis^ Rhadonema strongyloldes, Rlia- 
donema intestinaUSy Strongyloides intestinalis. 

^ize of egg — 70x45 microns. 
Forms : 

1. Parasitic adults, rartliogenetic females Avhicli 
live in liuman intestines, 2.2 to 3 mm in size. Eggs 
indistinguishable from those of hookworm, but only 
the embryos are passed in the feces. Elggs develop 
into 

2. Rhaditiform embryos, 200 to 400 microns in 
length, and in a few days these develop into 

3. Free living adult males and females. Male .7 
mm. and females 1 mm. in size. , The females pro- 
duce from 30 to 40 eggs, which develop into 

4. Free living rhabitiform embryos, 220 microns 
long. When they attain the size of 550 microns they 
moult and change into 

5. Filariform embryos having elongated cylin- 
drical esophagus. This is the infecting stage for 
man wliich occurs in much the same way asAyith the 
hook-worm, i e, through the skin or the mouth direct. 
In temperate zones cycles 3 and 4 may not occur. 




Method of diagnosis : 

1. Finding the rhabitiform embryo (2) in the 
fresh feces. 

2. Occasionally the eggs, strung together end to 
end and surrounded by a delicate tube are also found 
in the feces. 

Pathology — They live in the upper intestinal tract. 
Large numbers cause anaemia and diarrhea. 



284 
Trichinella spiralis. 

8is!e of male — 1.4 to 1.6 mm x 40 microns. 

Size of female — 3 to 4 mm x 60 microns. 

Pathology — A disease especially of slaughter- 
house rats, but also of dogs, cats, hogs and man, an 
accidental host. There are three stages of the in- 
fection. In the first the cysts present in the con- 
taminated digested meat are digested and males and 
females develop. The females burrough into the 
mucosa and proliferate rapidly. In the second 
stage they enter the lymphatics and gain access to 
the circulating blood. In the third stage they stop 
for the most part in striated muscle in which they 
become encysted. A myositis develops. 




Symptoms of infection — 

1 . Intestinal disturbance. In animals this is very 
severe. There is profound intoxication, a drop in 
the w.b.c. count with an associated drop in eosino- 
philes. 

2. Tremendous inflammation of the muscles asso- 
ciated with fever, enlargement of the spleen, and an 
increase in the polymorphonuclear neutrophile and 
eosinophile count. Sometimes there occur as many 
as SO per cent, eosinophiles. There is pain on mus- 
cular effort. The muscles of the eye ball, the calves 
and the diaphragm are all tender. After the first 
acute symptoms the patient doesn't suffer, but he is 
doomed to harbor the parasites the rest of his life. 

Diagnosis — Never made by finding the parasite in 
the stools. They can be found in the stomach and 



285 

intestines. In the dog the parasites can be found 
in the blood within 5 days after the infection, and 
this is the most satisfactory method in man in the 
early stages, of the disease. A syringe full of blood 
is removed f roin a vein and is laked by the addition 
of 2-3 per cent of acetic acid. The laked blood is 
centrifugalized and the supernatent fluid is decanted. 
The sediment is then washed if necessary and again 
centrifugalized. Preparations ,are made from the 
sediment and are examined under low power. In 
the later stages of the disease the diagnosis is made 
b}' excising a piece of muscle, which is then em- 
bedded, sectioned and stained. 

Mode of infection — Eating improperly cooked 
pork contaminated with the parasite. 

Trichiuris trichiura. 

Other names — Ascaris trichiura^ Trichocephalus 
trichiuruSy Trichocephalus homhvh, Trichocephalus 
dispar, Trichocephalus mastigodes, whip-worm. 

Size of male — 40 to 45 microns. 

Size of female — 45 to 50 microns. 

Size of eggs—oi, by 33 jnicrons. 

Pathology— Thej live in the colon eepeeially in 
the caecum and rarely in the appendix. They are 
an infrequent cause of anaemia and diarrhea. Enor- 
mous numbers may be present without symptoms. 

Mode of infection — Eating food contaminated 
with the embryos. The eggs passed in the feces re- 
quire considerable time for development. They re- 
sist freezing for many months. 

Method of diagnosis — Examine the feces for the 
characteristic eggs. 




286 

Ancylostoma duodenale. 

Otlicr nanic.^— Old World hook-worm, Uncinaria 
(liwdcual'hs, Stiongylus quadyidentatns, Dochmius 
(luri/lostouiinH, Sclcrostoiiia duodenale, ^trongylus 
duodenal i-^, Doehniius duodmalis. Enropeau hook- 
worm. 

Size of male — S to 10 mm long. 

Size of female — 12 to 18 mm long. 

Vharacteyistics of head — Two pairs of strong 
c'ui\'e(l ventral teeth. One pair of knob-like dorsal 
teeth. One pair of Aentral lancets. 

Size of eggs — 52 to 61 by 32 to 88 microns. 

Pathology — Thev inhabit the dnodenum, jejnnum 
"and ViplJer ilinm and cause severe anaemia through 
loss of blood* and toxin formation. Ground itch is 
the local" lesion of -the larva. 
'Modeyyfinff'dti'on—.- 

(a) Ingestion of unclean vegetables or contami- 
nated water. 

(bi Through the skin. Tlie larva bores through 
the skin of the feet and enters the lymph and blood 
stream. They reach the lungs and bore their way 
into the bronchi whence they are raised with the 
bronchial secretion and swallowed. 
Necator americanus. 

Other names — New World hook-worm, Umcaria 
americana, American hook-worm. 

Size of male — 6 to 9 mm long. 

Size of female — 8 to 15 mm long. 

Characteristics of head — A dorsal and a ventral 
pair of lips at mouth. Prominent dorso-median 
buccal teeth. Four buccal lancets. 

Size of eggs — 64 to 72 by 36 to 40 microns. 

Mode of infection and pathology — Same as for the 
Old World form. 
Method of diagnosis — 

Look for larva in the feces : 



287 ; 

1. By direct examination of the feces (40 per cent. 
yield). 

2. By adding water to the stool and passing it 
through a series of sieves and then allowing it to 
settle and examining the sediment. 

3. Increase specific gravity of the stool and cen- 
trifugalize. They are relatively light and come to 
the top where they can be secured. (55 per cent, 
yield.) 

4. Cultural method. Put stool in petrie dish and 
enough water to keep moist. Make a well in the 
center filled with Avater. Examine the water in the 
well from day to day. (99 per cent, yield.) 




Parasites havitig eggs resembling hookworpi eggs : 

1. Stroiigyloides stercoralis. Eggs infrequently 
passed in the feces. 

2. Trichostrongylus instahilis (See Jour, A.M. A. 
December 23, 1916, Pg. 1908). 

The eggs of this worm are larger and have a tend- 
ency to point at one end and be flattened at the 
other. There are from 4 to 32 segments within the 
egg. 

3. Haeinonchus coutortus. 

4. Strongylus coutortus. 

ASCARIS LUMBRICOIUES. 

&ize of hiale : 15 to 25 cm. 

Size of female: 20 to 40 cm. 

Characteristics of head: It has 3 conical lips. 

Color: Grayish to reddish yellow. 

Size of eggs : 50 to 75 microns by 36 to 55 microns. 



2SS 




Fertilized Unfertilized 

PaihoJogy. Tliev inhabit the small intestine, nsu- 
ally one or two being present. Occasionally large 
numbers arc found. While remaining in the in- 
te tine they rarely cause trouble, but when they 
wander up the common bile duct they often set up 
a pancreatitis and a hepatitis with liver abscesses. 
During anaesthesia they may be regurgitated, as 
well as at other times, and find their way into the 
air ])assage-\ Anaemia and intestinal obstruction 
are also caused at times by this infection. 

Si/hiptonis of infection : There are many. Itching 
at the anus, irritability, picking at the nose, rest- 
lessness, convulsions in children. A few worms may 
cause no symptoms. 

Mode of infection : The eggs are expelled in the 
feces and develop into embryos. These, when swal- 
lowed Avith contaminated drinking water or fruits, 
cause the disease. Eggs discharged in the feces are 
not immediately infective, but are only so after the 
development of the embryo. 

Method of diagnosis : Look for the eggs and worm ^ 
in the stools. There is usually an associated eos!- 
nophilia. 

TOXICORA CAXIS. 

Other names: Asca-iis canis, Ascaris liinil)ricns 
canis^.A^ckir-is^tereSy Ascaris caniculae, Ascaris cati, 
Asmris'tMciispiddta^ Ascaris felis, Ascaris loerneri, 
Ascmis inarginata, Ascaris aJata, Fusaria mystax. 

Si^e of male : 40 to 60 mm. long by 1 mm. thick. 

Size of female : 120 to 180 mm. long by 1 mm. thick. 
Size of egg : 68 to 72 microns. 



289 



Pathology: This worm is not uncommon and may 
be found accidentally in man. 




OXYURIS VERMICULARIS. 

other names: Ascaris vennicularis, Fusavia ver- 
micularis, Ascaris graecorum, pin-worm, thread- 
worm, seat-worm. 

Size of male : 3 to 5 mm. by 0.3 to 0.4 mm. 

Size of female : 10 mm. by 0.6 mm. 

Characteristics of head: Male has 6 pairs of 
papillae ; female has 3 small nodular lips. 

Size of eggs : 50 by 16 to 20 microns. 




Pathology: The early stages live in the small in- 
testine, where the^^ copulate. The males soon die 
and the females wander to the large bowel as far 
as the anus. They migrate from here and deposit 
their eggs in the skin about the anus and cause 
intense itching. The eggs lodge under the finger 
nails upon scratching, and often find their way into 
the mouth, causing auto-infection. The females may 
wander up the vagina, uterus, tubes or into the 
urethra and bladder. 

Method of diagnosis : Not readily made from the 
examination of the stools, but from the symptoms 
and the examination of the scrapings of the skin in 
the anal region, where the eggs are likely to be found. 



i 



291 

INDEX 

Abnormal myeloblasts , 216 

Abscess, sputum in 144 

Acetic acid in stomach analysis 115 

Acetone. 

Frommer's test for 93 

Gunning's test for 93 

, Lenoble's test for 93 

Lieben's test for ^ 93 

Legal's test for 92 

Achylia 109 

Acids in the urine. 

Quantitative determination of 34 

Variation of 33 

Acidosis 91 

Acute myeloid leukemia 242 

Albuminuria. 

Albumoses 8 

Bence-Jones protein 8, 14, 15 

Definition of 7 

Detection of 10 

False 7 

Nucleo-histones •. 8 

Origin 7 

Pseudo-globulin, etc 7 

Salient features of functional disturbance 9 

True 7 

With renal lesion 8 

Without renal lesion 8 

With transient renal injury 9 

Albumin. 

Heat and acetic acid test for 10 

Heat and nitric acid test for 11 

Heller's test for 11 

Potassium ferrocyanide and acetic acid test for 12 

Quantitative test for 12 

Alkapton bodies in urine 44 

Aleukemic lymphadenoses 239 

Allen's theory of. diabetes 95 

American hook-worm 286 

Ammonia in urine 65 

Ammonium sulphate test for globulin 13 

Amoebic dysentery, stolls in 158 

Amorphous phosphates and carbonates in urine 20 

Amyloid disease, stools in 157 

Anachlorhydria 109 

Anemias. 

Acute hemorrhagic 225 

Acute lymphatic 239 

Blood picture in secondary 224 

Chlorosis 228 

Chronic hemorrhagic 225 

General considerations of 223 



292 

Hemolytic 227, 245 

Pernicious anemia 228 

Secondary aplastic 226 

Ancliylostoma duodenale 286 

Anguillula intestinalis et stercoralis 282 

Animal parasites. 

In sputum 131 

In urine 27 

Anisocbromia 205 

Anuria 31 

Aplastic anemia 250 

Arnold's method of determining amount of chlorides in 

urine 48 

Ascaris alata 288 

" lumbricoides ; 287 

canis 288 

cati 288 

felis 288 

" graecorum 289 

marginata 288 

teres 288 

" tricuspidata -88 

*' vermicularis 289 

" werneri 288 

Avery's media for isolating influenza bacilli 143 

Avery's method of determining type of pneumoco: us. . . 137 

Bacilluria 26, 27 

Bang's titration method for sugar 85 

Banti's disease 245 

Barlow's disease 251 

Basophilic reaction in r. b. c 206 

Bayne-Jones quan. determination of chlorides in the urine 50 

Beef tape-worm 280, 281 

Bence-Jones protein in urine 8 

Character of urine in 15, 16 

Nature of protein 15 

Tests for 16 

Theories of origin 15 

Types of cases demonstrated in 14 

Benedict's test for sugar 73 

" quan. determination of sugar 85 

Benzidine test for blood 40 

Bial's method of detecting pentose in urine." 80 

Bile pigments in the urine 40 

Tests for 

Foam 42 

Gmelin's • • • 12 

Xakayama's 43 

Rosenbach's moditication of Gmelin's 43 

Smith's 13 

Bilharzia hematobia 279 

Bilirubin crystals in the urine 20 

Blood. 

Bleeding time determination 195 



295 

I'oygiilatioji liiue (Iclenuination 194 

Chart for special examination 197 

Cleaning glassware for 159 

Dust 182 

Counting 183 

Burger double counting chamber 186 

Hayem's solution for 184 

Red counts 185 

Sing'le counting chamber 186 

Requirements for 189 

Turk's solution for 185 

White counts 185 

Differential counting 175 

Fresh blood examination 179 

Hemoglobin determination 190 

In stools 153 

In urine 38 

Tests for 39 

Making smears of 160 

Coverslip method 160 

Slide method 162 

Criteria for 163 

Making stains of 164 

Ehrlich 171 

Jeuner 169 

AVilson 164 

Qualitative analysis of 159-183 

Quantitative analysis of 183, 197 

Boa's 

Method of determining gastric motility 123 

Quantitative determination of pepsin 119 

Test meal 104 

Test for HCl 108 

Bone marrow, varieties of 219 

Bothriocephalus latus ,.. 280 

" latissimus 280 

Bronchitis, sputum in 145 

Bronchiectasis, sputum in 145 

Bronchioliths in sputum 129 

Butyric acid in stomach analysis 115 

Cabot rings in r. b. c 206 

Calcium carbonate crystals in urine 21 

Calcium oxalate crystals in urine 18 

Calcium sulphate crystals in urine 19 

Carbonates in urine 53 

Carbohydrates 

Autoketonogenic f imction of 94 

Hamman's threshold test for 71 

Origin, function, regulation 70 

Carcinoma of rectum, stools in 156 

" " sigmoid, stools in . 157 

" " stomach, stools in 156 

Wolff- Junghan's test for 97 

( a si s in urine 23 



2^4 

Occurrence 25 

Theories of origin 24 

Types 24 

Cerebrospinal fluid 253 

Cytology of , . . . 255 

Colloidal gold test 257, 258 

Increase of 254 

Inorganic constituents of 254 

Normal 254 

Organic constituents 255 

Reactions of 255 

Xanthochromia in 256 

Charcot-Leyden crystals in sputum 131 

Cheesy masses in sputum 129 

Chladocaelium hepaticum 279 

Chlorides in the urine 47 

Qnantitative tests for 

Arnold's 48 

Bayne-Jones 50 

Lutke-Martius 49 

Volhardt's 48 

Retention of 48 

Salt excretion in 48 

Source 47 

Chlorlymphadenoses 238 

Chlorosis 228 

Cholera spirillum in stools 152 

Choluria. 40 

Sources 40, 41 

Chromatin staubchin in r. b, c 206 

Chronic lymphatic leukemia 236 

Chronic myeloid leukemia 240 

Chyluria 46 

Coagulation time determination 194 

Color index 203 

Coloring matter of urine 26 

Chart of 46 

Color of stools 155 

Combined acids in stomach analysis 110 

Method of detection. 

Einhorn method 110 

Incineration method 112 

Topfer's method Ill 

Congo red pepper, test for HCl , 107 

Constipation, stools in 157 

Cover-slip method of making blood smears 162 

Creatorrhea 146 

Creatinin in urine 68 

Criteria for good blood smears 163 

Crystals, in sputum . 131 

" in stools 154 

Cylindroids in urine 26 

Cystin crystals in urine 19 

Decomposition products in stools 150 

Diabetes insipidus 95 



295 

l)ialA'les mellitus 

Acidosis in 91 

Albumin and casts in 92 

Allen's theory of 95 

Amino acid N. in 92 

N. elimination in 91 

Urinary findings in 90 

Diacetic aeid in urine. 93 

Gerhardt's test for 93 

Diastase in urine, test for 97 

Diazo compounds in urine 44 

Ehrlich's test for 44 

Occurrence 45 

Dibothriocephalus latus 280, 281 

Dibothrium latum 280, 281 

Dimorphus muris 278 

Differential counting of w, b. c. n 176, 196 

Diphtheria, bacilli in sputum 142 

Leucocytes in 243 

Dipilidium caninum 280, 281 

" cucumerinum 280, 28J 

Diplacanthus nana 280, 281 

Distonum cavi 279 

•' capense 279 

" hematobium 279 

" hepaticum 279 

Dittrich's plugs in sputum 128 

Dochimus ancylostomum 286 

duodenalis 286 

Doramus ureometer for quantitative determination of N. 

in urine 58 

Duodeaal contents, examiBfttion of 120 

Dysentery bacilli in stools 152 

Echinococcus membranes in sputum 130 

Ectasia ; 123 

Ehrlich's 

Diazo reaction 44 

Egg yellow test 45 

Stain, criteria for 173 

technique for 171, 174 

Einhorn's 

Method of determinating combined acids Ill 

Method of sugar determination 84 

Elastic tissue in sputum 129 

Endamoeba histolytica 273 

Endo's media for isolation of typhoid bacilli 150 

Epithelial cells in urine 22 

Tuchlobulin in urine 7 

Ewald test meal 104 

Ewald-Siever's blood of determining gastric motility. . . . 123 
Extrusion of nucleus 201 

Fasciola hepatica 279 

" humana 279 

Fasting stomach analysis 102 



296 

Fnt 

Dirtereiiiiatiou of from soaps aud faUy acids 147 

In stools 14G 

Tape-worm 280, 281 

Feliling's test for sugar 73 

Fermentation 

Method of detecting sugar 76 

Method of estimating amount of sugar 81 

Ferments in stools, titration of 148 

Fibrinogen in urine 7 

Fibrinous casts in sputum 129 

Fibrinolysis test 195 

Filaria bancrof ti 282 

Fisher test meal 105 

Fish tape-worm ' 280, 281 

Foam test for bile 42 

Folin 

Method of N. determination 56 

Quantitative ammonia determ 66 

Quantitative creatinin determ 68 

Quantitative determ of acids in urine 34 

Quantitative urea determ 59 

Quantitative uric acid determ 64 

Fresh blood examination 179 

Fresh blood examination 179, 182 

Frommer's test for acetone 93 

Fusaria mystax 288 

" vermicularis 289 

Galactose In urine 75 

Gall stones in stools 153 

Gangrene, sputum in 144 

Gauchet's disease 245 

Gerhardt's test for diacetic acid. 93 

Gigantoey tes 204 

Glassware, cleaning of, for blood 159 

Globulin 

Ammonium sulphate method of detection 13 

Purdy's test for 13 

Glucose in urine 72 

Glycosuria 69, 95 

Glycuronic acid in urine 80 

Tollen's test for 80 

Gmelin's test for bile 42 

Guiac test for blood 40 

Gunning's test for acetone 93 

Gunzberg's 

Method of determining gastric absorption 124 

Test for HCl 107 

Hain's test for sugar .• • • • 74 

Hamman's threshold test for carbohydrates 71 

Hammerschlag's method for quantitative pepsin determ. 117 

Hayem's solution for diluting r. b. c 184 

Heat and acetic acid test for albumin 10 

Heat and nitric acid test for albumin 11 



Heavy metals in uriue 5.". 

liellei-'s test for albumm 11 

Hematoporpliyriu iu uriue 08, -J U 

Test for 38, 41 

Hematuria 38 

Beuzidiue test for 40 

Guiac test for 40 

Hemoglobin determination lUO 

Miesher method 192 

Requirements in 194 

Sahli method 190 

Talquist's method 190 

Hemoglobinuria 39 

Tests for : 

Heat and acetic acid 39 

Heller's 39 

Teichmann's hemiu 39 

Hemolytic anemia 227 

Hemophilia 251 

Hemoptysis 127 

Henoch's purpura 249 

Hexamitus duodenalis 278 

Hodgkin's disease 244 

Blood picture in 245 

Ho\y ell- Jolly bodies in r. b. c 20o 

Hydatid tape-worm 280, 281 

Hydrochloric acid 

Estimation of deficit 110 

Qualitative tests for 107. 108 

Quantitative tests for 108. 109 

Hymenolepis diminuta 280, 281 

flavopunctata 280. 281 

nana 280. 281 

murina 280, 281 

Hypoacidity, stools in 157 

Hyperchlorhydria 109 

Ideopathic purpura 247 

Incineration method of determining combined acids in 

stomach analysis Ill 

Indican in urine 37 

Obermayer's test for 37 

Infarction, sputum in 145 

Influenza bacilli in sputum 143 

Avery's media for isolation of 143 

Iron in urine 53 

Jaffe's test for creatinin 68 

Jenner's blood stain 

Technique and criteria for 169-1 70 

Karyolysis 201 

Kelling modification of Uffelman's test for lactic acid . . 114 

Kjeldahl N. determination 55 

Knop Huf ner quantitative test for urea 58 

Lactic acid 113 



29S 

Uffelmau's test for , lirJ 

Kelling's modification of Uffelman's test 114 

Sti'auss' test for 114 

Lactose in urine 75 

Rubner's test for 75 

Lamblia intestinalis 278 

Large mononuclears 178 

I-egal's test for acetone 92 

Le Noble's test for acetone 93 

Leptodera intestinalis et stercoralis 283 

Leube method of determining gastric moitility 123 

Leucocytosis, occurrence 221 

With differential blood pictures 221 

Leucin crystals in urine 19 

Leukemias 235 

Levulose in urine 78 

Seliwanoff 's test for 78 

Lieben's test for acetone 93 

Lipase, in stomach analysis 119 

Qualitative test for 120 

In urine 97 

Lipuria 46 

Litmus test for HCl 107 

Liver fluke 279 

Lobar pneumonia, sputum in 144 

Lohnstein's method of sugar determination 84 

Lumbar puncture 254 

Lutke-Martius quantitative determination of chlorides.. 49 

Lymphadenoses 236-240 

Acute lymphatic leukemia 238 

Aleukemic lymphadenoses 239 

Chlorlymphadenoses. 238 

Chronic lymphaitic leukemia 236 

Lymphocytes .^. 212 

Macrocytes 204 

Magnesium sulphate crystals in urine 20 

Malaria, leucocytes in 243 

Chart of ,'^4-. 276, 277 

Maltose in urine .'. . 76 

Marshall's urease method of quan. urea determination . . 59 

Matching of blood for transfusion 251 

Measles, leucocytes in 243 

Megakaryocytes 216 

Megalo-colon, stools in 158 

Megalocy tes 204 

Melanin in urine 43 

Meningitis, epidemic, leucocytes in 243 

Meningococci in sputum 138 

Agglutination of 140 

Cultivation of 139 

Mode of identification 139 

Olitsky's method for isolation and identification 140 

Metallic poisoning, stools in 157 

Methemoglobin in urine 40 



2'99 

Method of making hypotonic solutions for fragility tests 20t) 
' Mett's method for quantitative determination of pepsin . . 117 

Microcytes 204 

Miescher method of hemoglobin determination 192 

Monosaccharides in urine 78 

Mucus colitis, stools in , 157 

Mucus in stools 148 

Mucus threads in urine 22 

Myeloblasts 214 

Myelocytes 214 

Myeloses 

Acute myeloid leukemia — 242 

Chronic myeloid leukemia 240 

Nakayama's test for bile 43 

Necator americanus 286 

New world hook-worm 286 

Nitrogen 

Determination 55, 56 

Elimination in diabetes 91 

Excretion 55 

Partition 54 

Nitrogenous bodies in urine 54 

Noguchi, butyric acid reaction 255 

Nuclear particles in r. b. c 206 

Nucleo-histones in urine 8 

Nycturia 31 

Nylander's test for sugar 74 

Obermayer's tes^' for indican 37 

Obstructive jaundice, stools in 156 

Odor of stools 155 

Old world hook-worm 286 

Oligocythemia 203 

Oliguria 31 

Olitsky method for idenitification and isolation of manin- 

gococcus 140 

Orcin test for pentose 80 

Organic acids in stomach 112 

Acetic acid 115 

Butyric acid 114 

Lactic acid 113 

Quantitative tests for 113 

Organized sediments of the urine 22 

Origin of r. b. c 198 

Oxyuris vermicularis 289 

Pancreatic disease, stools in 156 

Pandy's reaction in spinal fluid 255 

Paragonimus westermanii 282 

Parasites, classification of, terms used in classification, 

etc 260-272 

Paroxysmal hemoglobinuria 245 

Pathological lymphocytes 216, 217 

Peliosis rheumatica 249 



300 

Pentose in the urine 70 

Bial's test for 80 

Orcin test for 80 

Pliloroglucin test for 80 

Penzolclt-Faber test for absorption 124 

Pepsin in the stomach 115, 116 

Qualitative test for 116 

Quantitative test for 117 

Mett's method 117 

Hamraerschlag's method 117 

Pepsin in the urine 96 

Test for 96 

Pernicious anemia 229 

Blood picture in 231 

Clinical symptoms 230 

Course of disease 231 

Differential dino.no<?is .- 232, 234 

"" rtusis, leucocytes in 242. 

Petroff's esg media 133 

Phenol derivatives in urine 44 

Phenylhydrazine test for sugar 77 

Phloroglucin test for pentose 80 

T^iTosphates in the urine 51 

Pigments, normal in urine 34 

Pin-worms 289 

Platelets 

Counting of 222 

Decreased in 223 

Function of 222 

Increased in 222 

In fresh blood 182 

Method of study 222 

Plasmam cells 216, 218 

Pneumococci in sputum 

Agglutination of , 135 

Avery's method of type determination 137 

Cultures of 136 

Isolation of 135 

Krumwiede and Valentine's method of type determ . . 138 

Precipitin test for type determination 136 

Pneumoliths in sputum 129 

Pneumonia, leucocytes in 244 

Polariscopic estimation of sugar 88 

Pollakiuria 32 

Poikilocytosis 204 

Polychromasia 205 

Poliomyelitis, leucocytes in • 242 

Polymorphonucleated neutrophiles 176, 210 

Polymorphonucleated eosinophHes 176, 210 

Polymorphonucleated basophileS 177, 211 

Polyuria 31 

Pork tape-worm 280, 281 

Potassium ferrocyanide and acetic acid test for albumin . 12 

Precipitin test in the urine for pneumococci 136 

Preservatives used for urine 29 



301 

Primary anemia 228 

Pseudo-globulin in urine 7 

Pulmonary oedema, sputum in 148 

Purdy's test for globulin 13 

Pus cells 

In stools 153 

In urine 22 

Pseudorhabditis stercoralis 283 

Purpura and pathological hemorrhages 246 

Purpura rheumatica 249, 250 

Reaction of the urine 38 

Red blood cells 

Abnormalities in size and shape 204 

Al)normal cells in the circulation 205 

Abnormalities in staining 205 

Counting of 184, 187 

Degeneration forms in fresh blood 180 

Function of 202 

In urine 23 

Normal number 201 

Origin 198 

Pathological variations 202 

Resistance of . . 208 

Variations in hemoglobin 203 

Vital staining of 208 

Red basophilia in r. b. c. with Giemsa stain 207 

Reducing bodies in the urine 69 

Table of 86, 87 

Renin in stomach analysis ; 118 

Boas quantitative determination of :........ 119 

Qualitative tests for • 110 

Rhadonema intestinalis 283 

" strongyloides ::....: 283 

Rieder cells ..'. 216, 217 

Riegel test meal ....'. 104 

Rosenbach's modification of Gmelin's test 43 

Ross-Jones' reaction in spinal fluid 205 

Russo's test in urine 45 

Saccharose in the urine 76 

Sahli 

Desmoid bag for determining absorption in stomach . . 125 

Hemoglobin determination 190 

Method of determining gastric motility 124 

Test meal ' 105 

Salzed test meal 105 

Scarlet fever, leucocytes in 243 

Scheme for detection of an unknown reducing body in 

the urine 82 

Schistosomium hematobium 279 

Schlessinger's test for urobilin .36 

Sclerostoma duodenalis 286 

Schlosing quantitative determination of sugar in urine. 60 



302 

f«ldimiclt and Strasburger diet for pancreatic efficiency 

test 149 

Schonlein's disease 249 

Schuffner's granules in r. b. c 207 

Sehultz's law 117 

Scurvy 251 

Seat-worms 289 

Secondary anemia 

Blood picture in 224 

Causes 224 

Secondary aplastic anemia 226 

Sediments in the urine 
Unorganized 

Amorphous phosphates and carbonates 20 

Bilirubin crystals 20 

Calcium carbonate crystals 21 

Calcium oxalate crystals 18 

Calcium sulphate crystals 19 

Cholesterin crystals 20 

Cystin crystals , . . . 19 

Hippuric acid crystals 20 

Leucin crystals 19 

Scheme for running down inorganic sediments 21 

Triple phosphates 20 

Tyrosin crystals 19 

Uric acid crystals 18 

Xanthin crystals 19 

Organized 

Casts 23 

Epithelial cells 22 

Mucus threads 22 

Pus cells 22 

Red blood cells 23 

Tissue fragments 23 

Tripperf aden 23 

Seliwanofif's test for levulose 78 

Serum albumin in urine 7 

Serum globulin in urine 7 

Slide method of making blood smears 162 

Smith's test for bile 43 

Specific gravity of urine 32 

Clinical value of 32 

Methods of determination 32 

Spectroscopic chart 41 

Spermatozoa in urine 23 

Splenic enlargement with anemia 245 

Splenomegaly with anemia, conditions with 245 

Sprue, stools in 157 

Sputum 

Amount 128 

Animal parasites in ".. 131 

Bacillus mucosus sapculatus in 142 

Bronchi oliths in 129 

Cheesy masses In 129 

Collection of , 127 



303 

Color of 127 

Crystals in 130 

Curshmanu's spirals in 128 

Diphtheria bacillus in 142 

Echinococcus membranes in 130 

Fibrinous casts in 129 

Fungi in 132 

Heart failure cells in 130 

Influenza bacilli in 143 

In various diseases 144-146 

Macroscopical examination, of 128 

Meningococci in 138 

Microscopical examination of 130 

Odor of 128 

Pneumococcus in 134 

Pneumoliths in 129 

Spirocheta pallida in 143 

Spironema vincenti in 143 

Staining of blood 164 

Steatorrhea 146 

Stomach 

Absorption in 124, 125 

Digestion in 121 

MotiUty of 122-124 

Stomach analysis 

Blood in 115 

Test for 39 

Combined acids in 110 ' 

Estimation of HCl deficit 110 

Expression of acidity lCt9 

Fasting stomach 102, l(]f6 

Ferments in 115-119 

Organic acids in 112-115 

Quantitative tests for HCl .108, 109 

Stomach tube 
Contraindications for 102 

Stools 

Bacteria in 150, 152 

Blood in 153 

Color of 155 

Decomposition products in 150 

Crystals in 154 

Fat in. . . ^ 146 

Fermei^ts in 148 

Foreign bodies in 153 

In diseases 158 

Mucus in c 148 

Odor of 156, 157 

Pus cells in 153 

Sugar and starch in 147 

Tumor fragments in 153 

Urobilin in 147 

Strauss test for lactic acid 114 

Stricture of rectum, stools in 157 



304 

J^roiigyloides .stercoralis 2S2 

iutestiualis 283 

Slroiigylus diiodenalis 286 

quadrideutatus 286 

Sugar iu the urine 73 

Benedict's test for 73 

I'elilin.u's te>'t for 73 

Fermentation test for 76 

Haiu's test for 7-1 

Xyiander's test for 74 

Plu^nylliydrazine test for .- 77 

(^>.iantitatiA'e estimation of 

Bang-'s method 85 

Benedict's me.hod 85 

1 ermentation metliod 84 

Ein'jorn 84 

Lohn tein • 84 

Sj). (4r.-Fermtntation method 84 

Uriniry output sp. gf. method 84 

Sulphates in the urine 27 

Synptomatic purpura 247 

Taenia aegyptica 280, 281 

canina 

cucumerina 

" echinococcus 

" elliptica 

" flavo punctata 

" lata 

" leptocephala 

" minimus . . , 

" moniliformis 

nana 

'■ saginata , 

" soleum 

" varerina 

Talquist's hemoglobin determination 190 

Tape-worm, table of 280, 281 

Test meals for stomach analysis 103 

Boas 104 

Ewald 101 

Fisher 105 

Kiegel : \. 101 

Sahli \.. :...... 105 

Salzer i ^^ 105 

Thecosoma ^-Jv. . . . 279 

Thread worms. . 289 

Tissue fragments in urine 23 

Tollen's test for glycuronic acid in urine. 80 

Topfer's test for HCl 107 

" determination of combined acids Ill 

Toxicora cania 288 

Transfusions, matching blood for 251 

Transitional cells 213 

Trichinella spiralis 284 

Trichiuris trichirura 285 



305 

Tricboceplialus clispar 2S5 

" hominis 285 

" mastigodes 285 

" tricliiiirus 285 

Trichomonas iiitestinalis 275 

vaginalis 275 

Triple phosphates in urine 20 

Tripperfaden 23 

Tropeolin test for HCl , .... 108 

True purpura 248 

Trypanosoma gambiense 274 

Tsuchiya's reagent 13 

Tubercle bacillus 

(Cultivation of 133 

in sputum 132 

In stools 150 

Stain for 132 

Tuberculosis, sputum in 144 

" stools in 158 

Tumor fragments in stools 153 

T-urk's solution for diluting w. b. c 185 

T^urk's cells l 216, 217 

Tyhpoid bacilli in stools 150 

Endo's media for isolation 150 

Typhoid, stools in 158 

" leucocytes in 244 

Tyrosin crystals in urine 19 

Uff elman's test for lactic acid 113 

Unarmed tape-worm 280, 281 

Uncinaria americana 286 

■' duodenalis 286 

Urate sediments in urine 18 

Uric acid crystals in urine 18 

Urine 

Abnormal pigments of 38 

Acid bodies in 92 

Alkapton bodies in 44 

Ammonia in 65 

Quantitative determination 66 

Amount excreted 30 

Bile pigments in 40 

Carbonates in 53 

Collection of 24 hr. specimens 28 

Chart of coloring matter in 46 

Chlorides of 47-51 

Chyluria in 46 

Ferments in 96 

Findings in diabetes 90 

(Jlycuronic acid in 80 

Diazo compounds in 44 

Creatinin in 67 

Tests for 68 

Examination criteria 27 

General considerations 38, 40 



306 

Galactose in 75 

Glucose in 72 

Heavy metals in 58 

Iron in 53 

Inorganic urinary constituents 47 

Indican in 37 

Nitrogenous bodies of 54 

Llpuria in 46 

Lactose in 75 

Levulose in 78 

Maltose in 76 

Melanin in 43 

Metheoglobin in 40 

Phosphates in '. 51 

Monosaccharides in , 78 

Pentose in 79 

Precipitin test for pneumococcus in 136 

Reducing bodies in 69 

Optical activity of 47 

Phenol derivatives in 44 

Saccharose in , 76 

Sclieme for detection of reducing bodies in 82 

Specific gi'avity of 32 

Normal pigments of 34 

Sugai- in 73 

Sulphates in 52 

Lactose in 75 

Levulose in 78 

Melanin in 43 

Methemoglobin in '. 40 

. Phosphates in 51 

Monosaccharides in 78 

Pentose in 79 

Precipitin test for pneumococcus in 136 

Reducing bodies in 69 

Optical activity of . . ; 47 

Phenol derivatives in 44 

Saccharose in 76 

Scheme for detection of reducing bodies in 82 

Specific gravity of 32 

Normal pigments of 34 

Sugar in. , 73 

Sulphates in 52 

Preservative used for 29 

Physical properties of 29 

Undetermined N. in 68 

Urea in 57 

Qualitative tests for 58 

Quantitative tests for 58, 59^ 

Uric acid in 61 

Factors modifying excretion of 64 

Folin's quan. method of determination 64 

Properties of 62 

Relation to gout 63 

Urobilin in stools 147 



307 

Uroclii'oiiie.' -'• I 

rrocrytluiii .*! I 

rr;)])iliii in urine :.". 

Tos:s for , a,; 

Vnn.uhn's method of vital staining l-OS 

A'ital stainin:^ of r. b. c 20S 

Vomitus, types [A). 1{]() 

Volhardt's quantitative determination of chlorides -hs 

AVeyl's te-^t for creatinin . ( S 

V^liip-worm i; .'. 

White blood cells 

Abnormal myeloblasts . 21(> 

Changes in count '. \ " 2_() 

( lttssilica:ion of 2!).! 

DifCerential counts, remarks on . .' . 220 

Evidence of youth of 21S 

Findings in infectious diseases 2)2 

Irritation f(irms 21G. 217 

Lymphocytes 21 :' 

Megakarvocvtes 216. 21S 

Myeloblasts 214 

Myelocytes 214 

Plasma cells 216. 21M 

P. M. X 210 

Fresh blood examination of IS i 

P. M. E 2:0 

Pathological lymphocytes 21 '. 2" 7 

Transitionals •. . . 21.') 

Widal. Abrami. and F>rule method of vital stainln: of 

r. b. e 20:^ 

White blood counting ISS, iSo. "^ 'v> 

Wilson stain for blood 164 

Criteria for 1 7 

Winternitz method of determining gastric motility 128 

Wohlgemuth's test for diastase IK 

Wolff -Junghan's test for carcinoma of stomach 125 

Xanthin crystals in urine 19 

Xanthochromia 253 

Ziehl-Nielsen slain for tubercle bacilli i:J2 



i. 



